Add Medical and Surgical History

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Manage Patient History Records

You can update or remove the patient history records for medical, surgical, interim, social, and family categories. Open NextGen® Enterprise EHR. Open the Intake template, and then expand the History Summary section. Do one of the following: To update or remove a history record for the Past Medical/Surgical category on the relevant template, select Add Past Medical/Surgical Hx. To update or remove a history record for the Social category on the relevant template, select Select Social Hx to Add/Edit, and then select the appropriate option from the list. To update or remove a history record for the Interim and Family categories on relevant templates, select the record from the grid, right-click, and then select Open. Parent topic: Patient's History Summary Parent topic: Pediatric History Summary

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Add Interim History

Open NextGen® Enterprise EHR. Open the Intake template. In the History Summary section, select Interim. Select Add Interim. Document the reported history information. Select Save and then select Close.The history record appears in the grid. Parent topic: Patient's History Summary Parent topic: Pediatric History Summary

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Add Family History

You can add the family history of a patient from the Family category in the History Summary panel or in the Family panel on the Histories template. To indicate that no relevant history is available, select No relevant family history. If there is no known family history for an adopted patient, select Adopted - no family history known, and skip documenting the Family category details. Open NextGen® Enterprise EHR. To open the Family Health History template, do one of the following: On the Histories template, expand the Family panel, and select Add. In the History Summary panel on the Intake template, select Family, and select Add. Family Health History On the Family Health History template, NextGen® Enterprise EHR automatically fills the Specialty field with the current specialty. If there is no family history to document, select the No family history check box. Select the Relationship field, and select a description from the Family relation list. In Family member name, enter the name of

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Categories in History Summary

You can document various history details for a patient in different categories in the History Summary panel. The left pane of History Summary panel on the Intake template includes a list of categories to select and view the documented data. The following table provides a description of each category. Category Description Past Medical/Surgical Enables you to document the patient's past medical and surgical history. You can document the patient history using Add. If no medical or surgical history exists, you can select the No relevant past medical/surgical history checkbox. You cannot select the checkbox if medical surgical history present in the grid. Interim Enables you to document the interim history. Social Enables you to document the Social history. You can select an option from the left pane using Add/Edit. Family Enables you to document the Family history. You can document the details using Add. Diagnostic Enables you to document the diagnostic history. You can document the detail

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Update Past Medical History

You can update the past medical history for a patient on the Edit Past Medical History template. Open NextGen® Enterprise EHR. Do one of the following to update past medical history on the Edit Past Medical History template: On the Histories template, in Medical/Surgical/Interim, select the corresponding medical or surgical record from the grid that you want to update, and select Edit. In the History Summary panel on Intake, in Past Medical/Surgical, select the row on the grid that you want to update, and select Edit. The Edit Past Medical History template opens. Edit Past Medical History Note: The Edit Past Medical History template can also be accessed from the Past Medical History template by selecting an entry on the Past Medical History grid and selecting Edit. Update the necessary details. Enter any additional comments in the Append to previous comments field. Select Save and then select Close. Parent topic: Add Medical and Surgical History

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Documenting a Patient's History Summary

You can add, update, delete, and review a patient's history summary details from the History Summary panel. You can document a patient's history details in the History Summary panel in the following categories: Past Medical/Surgical Interim Social Family Diagnostic The History Summary panel also displays the patient history documented by the intake staff on the Histories template. You can add diagnostic studies with a documented Result or Interpretation to the grid in the Reason for Visit panel by selecting the Add to HPI Grid button. The grid includes a list of categories on the left pane to select and view the documented data. You can filter the patient history records by selecting the Medical History or Surgical History option for Past Medical/Surgical. You can view and enter confidential details provided by the patient during the course of the encounter using The Confidential link. You can select History Review to open the History Review template and select the applicable option to

Add Medical and Surgical History

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