Add Diagnostic History

You can add the diagnostic history of a patient from the Diagnostic category in the History Summary panel or from the Diagnostic Studies panel on the Histories template.

1. Open NextGen® Enterprise EHR.
2. To document the diagnostic history, do one of the following:
   • On the Histories template, expand the Diagnostic Studies panel, and select Add.
   • In the History Summary panel on the Intake template, select Diagnostic, and select Add/Edit.
   The Diagnostic History Entry template opens.

   

3. Select Diagnostic study type, select the study type, and then select OK.
4. Select Diagnostic study, select an option, and then select OK.
   The Procedure code field is automatically filled.
5. If the diagnostic study is performed outside your practice, select Ordered elsewhere.
6. Select Side and Site, and select the appropriate option.
7. Select Date performed, and enter the date. If the exact date is unknown, select Approximated performed date.
   NextGen® Enterprise EHR automatically fills the Date Completed field with the same date as that of Date performed.
8. To change the date, select the Date Completed field, and select another date.
9. Select Specialty, and select the specialty.
10. In Performed by, enter the name of the person who performed the diagnostic study.
11. In Location, select where the diagnostic study is done.
12. In the Study Result section, select an interpretation from Interpretation, and then enter the interpretation of the result in Result.
13. Enter your comments.
14. Select Add to Grid.
    Note: You can add the additional details of an order in the data grid on the Diagnostic Study - Orders template. For more information, go to NextGen Healthcare Success Community, and download the latest My Plan Template Set User Guide for NextGen® Adaptive Content Engine.
15. Select OK.
    In the History Summary panel on the Intake template, an abnormal interpretation appears in bold font and a yellow icon appears next to the interpretation in the grid.