Document a Routine Visit

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document a Specific Complaint

After the intake staff completes their work with the patient, you can document the patient encounter. An essential part of the workflow is to complete the appropriate physical examination template. The grid functionality on the Dermatology physical examination (PE) templates enables you to document multiple complaints on a single PE template. On Dermatology Home Page template, review the patient's historical information documented in the previous encounters. On the Histories template, review the patient information and make the desired modifications. On the GET template, and add your findings using Graphical Exam Tool. On the SOAP template, view the details of reason for entered by the intake staff in the Reason for Visit panel. You can enter additional reasons for visit. In the Review of Systems panel, to document patient's signs and symptoms, do one of the following: Click the ROS defaults field, and then select an appropriate default ROS from the list. Click DERM - ROS and do one of

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Routine Visit or Specific Complaint

You must follow the normal office visit procedure as follows: Document a Reason for Visit Fill in the appropriate History of Present Illness (HPI) template Complete a Review of Systems Perform a Physical Examination A patient who has come in to address a specific complaint such as acne, rash, warts, or lesions, might require a biopsy or non-surgical treatment. Based on the results of the skin examination, you may choose to schedule or perform any of the following: Biopsy to rule out skin cancer. Cryosurgery to treat actinic keratosis, seborrheic keratosis, or viral wart. Blue light (photodynamic) treatment for actinic keratosis. Topical treatment for eczema, certain warts, actinic keratosis, or certain basal and squamous cell cancers. These findings also may require a biopsy. As a provider, your actions depend on whether you intend to bill for an office visit, a procedure, or both. If you plan to bill the patient for an office visit, you can select the Office Visit visit type. In addit

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Review of Systems Details

Open the SOAP template. In the Review of Systems panel, do one of the following: To select normal for all systems, click the ROS Defaults field, and then select default ROS from the list. To document the findings for multiple systems on a single template, click Derm ROS To document the findings for a specific system, locate the respective system on the ROS template, and then document your findings. To mark negative for all symptoms in a system, select All Neg in that system. To document the findings in detail for a specific system, click the respective system link, and then document the findings. Document the updates in the template. Click Save & Close. The option exists to save the documented information in the ROS template as the default set with a unique name, allowing you to use it again when documenting on the same template during future patient encounters. To copy the previous review of systems information to the current encounter, click ROS History. The Historical Information wi

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Review of Systems

The Review of Systems panel enables you to document the findings after reviewing a list of systems. Click Derm - ROS in the left pane to access the Dermatology - ROS template. Note: To copy the previous review of systems information to the current encounter, click ROS History. The Historical Information window opens, click Copy ROS & Close to copy previous review of systems information to the current encounter on the SOAP template. On the Historical Information window you can view Encounter Date, Provider, Reason for Visit/HPI, Diagnosis and copy System and Findings, Comments and Narrative to the current encounter. You can search or filter for specific content on the Historical information window by using the picklist available for each field except Findings,Comments and Narrative. For Findings, Comments and Narrative, you must type minimum 3 characters to enable the Search button. Click ROS Default field to access the Td Dbp Filter window with default ROS questions.This list can be mo

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Exam Findings with GET

Open NextGen® Enterprise EHR. On the Intake template, select the Specialty as Dermatology and the Visit Type as Office Visit. In the Reason for Visit panel, select a reason for visit. To open the Graphical Exam Tool template, click the GET tab. On the Graphical Exam Tool template, the Reason for Visit pane shows the first reason for visit and you can do the following in the pane: Use the right arrow to display the next reason for visit. Use the left arrow (when enabled) to display the previous reason for visit. Note: You can add all the findings for a visit on a single reason for visit, or you can add the appropriate findings for each reason for visit. The right arrow is enabled if there are additional reasons for the visit. Select the areas examined on the Areas Examined panel. Click a finding in the FINDINGS list and then click the locations on the image where that finding appears.As you add findings, a record for each finding is added to the Reason for Visit grid beneath the image.

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Complete the Derm Quick HPI Template

The Derm Quick HPI template enables you to enter the following patient information: General information about the patient's chief concern Dermatology specific information, including location of concern, skin type, cancer history and date of last exam Current and previous treatments Additional relevant details You can add up to six complaints on the HPI grid. In the Reason for Visit panel of the SOAP template, click derm quick hpi in the left pane.The Derm Quick HPI template opens. In the General panel, click the Concern field and select the patient's chief concern from the resulting list. To enter a duration for the concern, click the Duration field and use the resulting calculator. If this is a follow-up exam for treatment of the chief concern, click the Follow up check box. To select the current status of the concern, click Status. To indicate the date that the patient first noticed the concern, click Lesion noticed. If appropriate, select a Severity for the concern, either Mild, Mod

Document a Routine Visit

Recommendations

Document a Specific Complaint

Routine Visit or Specific Complaint

Document Review of Systems Details

Document Review of Systems

Document Exam Findings with GET

Complete the Derm Quick HPI Template

Document a Routine Visit

Document a Specific Complaint

Routine Visit or Specific Complaint

Document Review of Systems Details

Document Review of Systems

Document Exam Findings with GET

Complete the Derm Quick HPI Template