Document an Assessment Plan

You can document patient plan and provider plan details for the patient's assessment.

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 A/P Details tab.
   The Assessment Plan Details template opens.
5. Select an assessment from the Today's Assessment grid.
   The existing assessment details appear in the corresponding fields.
6. Enter the details or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections.
7. To enter follow-up appointment and disposition information, select Follow Up.
8. To document counseling educational details and factors, select the Counseling Details.
9. To enter post-operative details, select Postoperative Quality Reporting.
10. For more information on the associated quality measure, select Q.
11. Select Save & Close.