Associate Multiple Diagnoses with an Order

You can document multiple diagnoses with an order in the Associate Multiple Diagnoses to Orders template.

1. Open NextGen® Enterprise EHR.
2. Open a patient's record, and then open an encounter.
3. Open the Intake template, select the specialty as Family Practice and the visit type as Office Visit, and then select My Plan.
4. Select the Diagnosis tab and then select the Associate Diagnoses link.
   The Associate Multiple Diagnoses to Orders template opens.

   Note:

   • If the order for the diagnostic study is selected but not yet placed, the selected order appears in the gray read-only Order field. The first assessment selected for the order appears in the gray read-only first diagnosis field Dx1, with its code and status, if a status is selected. The Active Diagnoses grid displays all diagnoses active for the patient.
     

   • If the order for the diagnostic study is placed but not processed through Lab/Radiology Order Processing, the order appears in the Diagnostic Orders grid. The Active Diagnoses grid displays all diagnoses active for the patient.
5. For an order that is placed, select the order in the Diagnostic Orders grid.
   The selected order appears in the Order field. The first assessment selected for the order appears in the first diagnosis field Dx1, with its code and status, if a status is selected.
6. To associate an additional assessment to the selected order, do one of the following:
   • Select an assessment from the Active Diagnoses grid.
   • The selected assessment and its code appears in the first empty diagnosis field, starting with Dx2.
   • Select the first empty diagnosis field, starting with Dx2, and select a diagnosis from the diagnosis search window.
   The selected diagnosis and its code appear in the selected diagnosis field.
7. Select a status for each additional assessment you add, if required.
8. If required, check medical necessity and the Advanced Beneficiary Notice (ABN) waiver.
   If your system is configured to turn on the medical necessity verification process on the Practice Configuration practice template, the Medical necessity text field and ABN are visible. If patient demographic information includes insurance and region, the application automatically runs a medical necessity check against all of the diagnoses associated with the selected order, and the result appears in the Medical necessity text field.

   For more information on the Medical Necessity practice setting and Medical Necessity, go to NextGen Healthcare Success Community, and download the Practice Configuration Template User Guide for NextGen® Adaptive Content Engine and Medical Necessity User Guide for NextGen® Enterprise, respectively.

   1. If the Medical necessity text field displays Medical Necessity Met or Cannot Confirm, ABN is not available and there is no further action.
      

   2. If the Medical necessity text field displays Needs Waiver, then ABN is turned on.
      

   3. Select ABN.
      The Advanced Beneficiary Notice Waiver Required template opens.
   4. Select the option for Advanced Beneficiary Notice waiver that applies, and select Add to ABN
      The Advanced Beneficiary Notice Waiver Required template closes.
9. Select a preferred sort order for all diagnoses associated with the order.
   Before the order is placed, you cannot change the diagnosis that appears in Dx1, but you can sort diagnoses from Dx2 to Dx4. If the order is placed, you can sort all of the diagnoses associated with the order, from Dx1 to Dx4.
10. Select Update.
    The additional diagnoses are associated with the order and appear in the Active Diagnoses grid.
11. Select Close.