Document a Physical Exam

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

The Pre-procedure Evaluation panel allows you to view and add patient's physical exam findings and generate the ASC Chart Note document after review and signoff. You can use the My Phrases link at the top-right of the Comments field to add comments. For more information on managing and using the My Phrases functionality, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. After entering the appropriate data in the Physical Exam, select the No or Yes option for the Patient remains an appropriate candidate to undergo the planned procedure checbox to indicate whether or not the physician can consider performing any further planned procedures on the patient. The following options are available at the bottom of the Pre-Procedure Evaluation panel: Normal history and physical - Indicates that the pre-procedure evaluation findings are normal. History and physical reviewed, no changes - Indicates that the existing pre-pro

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Physical Exams

As part of the provider workflow, you can document and manage physical exams performed for a patient. Open NextGen® Enterprise EHR. Open the SOAP template, and then expand the Physical Exam panel. To document findings for multiple physical exams on a single template, select One Page Exam from the left navigation bar. Note: You can also select Load to quickly load any saved physical exam findings, or Save to save the documented physical exam findings to use them on other encounters. To document findings for a single physical exam, select an appropriate link from the left navigation bar. To document findings for a physical exam that does not appear in the left navigation bar, select Additional. To copy physical exam findings from a previous encounter to the current encounter, select Physical Exam History.If you have copied and edited information from a previous encounter, a label appears in the Physical Exam panel and applicable documents indicating that information is copied and edited.

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Physical Exam Findings

You can document the complete physical examination details of a patient on the SOAP template. The One Page Exam link opens a gender-specific or a gender-neutral, one-page physical exam template. Based on the configuration in the Physical Exam panel of the Framework Content system template and the selection of the Enable Gender Neutral PE checkbox on the Practice Configuration template, the gender-specific or a gender-neutral, one-page physical exam template opens. For more information, go to NextGen Healthcare Success Community, and download the Framework Content System Template for NextGen® Adaptive Content Engine and Practice Configuration Template User Guide for NextGen® Adaptive Content Engine. Open NextGen® Enterprise EHR. On the SOAP template, expand the Physical Exam panel. Select One Page Exam. The One Page - Physical Exam template opens. One Page - Physical Exam Document your findings on the template. Note: To save the documented value as the default set, you can select the Qu

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Copy Physical Exam Findings from Previous Encounters

You can copy physical exam findings 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 Physical Exam panel. Select Physical Exam History.The Historical Information window opens. Note: The records are displayed for the default duration configured in the Copy Previous Visit Information section of the Practice Configuration template. For more information, go to NextGen Healthcare Success Community, and download the Practice Configuration Template User Guide for NextGen® Adaptive Content Engine. 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. Select the record to copy, and then select Copy Physical Exam &

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document a Multi System Exam on the SOAP Template

You can document the complete physical examination details of a patient on the SOAP template. The One Page Exam link in the left pane on the Physical Exam panel allows you to open the One Page - Physical Exam template. Note: Based on how the One Page Exam template is configured in the Physical Exam section on the Framework Content system template, and whether the Enable Gender Neutral PE checkbox is turned on in the SOGI/Transgender section on the Practice Configuration template, a gender-specific or a gender-neutral One Page - Physical Exam template opens. For more information, go to NextGen Healthcare Success Community, and download the Framework Content System Template for NextGen® Adaptive Content Engine and Practice Configuration Template User Guide for NextGen® Adaptive Content Engine. Open NextGen® Enterprise EHR. Open the SOAP template. In Physical Exam, select the One Page Exam link in the left pane.The One Page - Physical Exam template opens. one_page_physical_exam_template E

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Manage Physical Exam Submenus

You can add or delete a physical exam item from the Physical Exam list. Add a sub-menu to display before or after the selection of the Physical Exam on the Framework Content system template. You can add a sub-menu only if there is a correlating configuration in the Manage Custom Links template. For more information on the Manage Custom Links practice template, go to NextGen Healthcare Success Community, and download the Manage Custom Links Practice Template for NextGen® Adaptive Content Engine. Open NextGen® Enterprise EHR. Open the Framework Content system template. Select the Physical Exam panel. Select the all option. In the grid, select a Physical Exam Item. In the Submenus section, select before and type the items in the fields (for example, left, right, and bilateral). Physical Exam If a sub-menu listing is required after the physical exam item, select after and type the items in the field. If a sub-menu listing is required before and after the physical exam item, select Submenu

Document a Physical Exam

Recommendations

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

Document Physical Exams

Document Physical Exam Findings

Copy Physical Exam Findings from Previous Encounters

Document a Multi System Exam on the SOAP Template

Manage Physical Exam Submenus

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

Document Physical Exams

Document Physical Exam Findings

Copy Physical Exam Findings from Previous Encounters

Document a Multi System Exam on the SOAP Template

Manage Physical Exam Submenus