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Add an Assessment on the SOAP Template
You can enter assessment and plan details on the
Add Assessment
tabbed template.
Open
NextGen® Enterprise EHR
.
From the
SOAP
template, in the
Assessment / Plan
panel, select
Add/Update
.
The
Add or Update Assessment
tabbed template set opens.
Select an assessment.
Enter the
Status
,
Side
,
Site
,
Impression
, and
Differential dx
fields.
Select
Add/Update
.
The assessment is added to the
Today's Assessment
grid.
Select
Save & Close
.
Add an Assessment on the SOAP Template
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Update an Assessment on the SOAP Template
Open NextGen® Enterprise EHR. On the SOAP template, in the Assessment / Plan panel, select an assessment you want to update in the grid. Select Add/Update.The Add or Update Assessment tabbed template set opens. Make changes to the assessment. Select Save & Close. Parent topic: Document Assessments and Plans
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Remove an Assessment on the SOAP Template
Open NextGen® Enterprise EHR. In the Assessment / Plan panel, select an assessment in the grid. The Add or Update Assessment template opens. In the Today's Assessment grid, select an assessment. Select Remove. Select Yes on the confirmation message. Select Save & Close. Parent topic: Document Assessments and Plans
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Open the Assessment Plan Details Template
Some specialties (for example, Cardiology) open the Assessment Plan Details template differently. Refer to the specialty guide for your version of NextGen® Adaptive Content Engine available on NextGen Healthcare Success Community for instructions if the following does not apply: Open NextGen® Enterprise EHR. On the SOAP template, in Assessment/Plan, select A/P Details.The Assessment Plan Details template opens. Assessment Plan Details options Parent topic: Add or Update Assessment Template Parent topic: Open the Assessments Tab Parent topic: Document Assessments and Plans Parent topic: Entering Assessments, Impressions, Differential Diagnoses, and Associated Details
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Follow-up Details
You can enter follow-up appointment and disposition details on the Follow-up/Disposition template. Open NextGen® Enterprise EHR. Open the SOAP template. In the Assessment / Plan panel, select the Follow Up button.The Follow-up/Disposition template opens. Follow-up/Disposition template The Follow-up/Disposition template is part of a group of templates that use the last assessment or diagnosis selected on any of the templates in the group as the working assessment. The application defaults to the current working assessment. If required, you can select another assessment, which becomes the new working assessment that carries forward to the other templates in the group. Do one of the following: Select the diagnosis in the grid. In the Follow-up section, select follow up along with other details and the suggested time for the follow-up visit. To select a new diagnosis or modify an existing assessment for the current patient, select Add/Edit Assessment. With the correct description selected
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Copy Assessments from Previous Encounters
You can copy assessments from previous encounters of a patient to the current encounter instead of manually adding them. Open NextGen® Enterprise EHR. Open the SOAP template, and then expand the Assessment/Plan panel. Select Dx/AP History.The Assessment, Diagnosis Copy Forward window opens. Note: By default, the All Assessments option is selected and records are displayed for the default duration configured in the Copy Previous Visit Information section of the Practice Configuration template. To copy assessments from a specific encounter, select Encounter Assessments. To filter the records in the grid, enter the search criteria in Filter by, and then select Search. Note: If the records are displayed from any sensitive encounter, an asterisk (*) appears on the record in the Sensitive column to help you decide whether to copy such records and update the current encounter as sensitive. To select an assessment, do one of the following: From the All Assessments grid, select the record, and
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document an Assessment Plan
You can document patient plan and provider plan details for the patient's assessment. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. Open the Intake template, select the specialty as Family Practice and the visit type as Office Visit, and then select My Plan. Select the A/P Details tab.The Assessment Plan Details template opens. Select an assessment from the Today's Assessment grid.The existing assessment details appear in the corresponding fields. Enter the details or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections. To enter follow-up appointment and disposition information, select Follow Up. To document counseling educational details and factors, select the Counseling Details. To enter post-operative details, select Postoperative Quality Reporting. For more information on the associated quality measure, select Q. Select Save & Close. Document Follow-up Details Yo
