Document Chronic Conditions

You can document patient's chronic condition details in the Reason for Visit panel.

1. Open NextGen® Enterprise EHR.
2. In the Reason for Visit panel, select the Chronic Conditions button.
   The Chronic Conditions template opens.

   

   The provider uses the Overall chronic conditions HPI field to enter notes regarding all chronic conditions of a patient.

3. Select the Flowsheet link to open the Flowsheets template.
4. Select the Immunizations link to add immunizations details.
5. Select the My Phrases link to open My Phrases functionality.
6. Select Add Problem to search for and add a problem.
   The added problems appear in the Problem Description list on the left. The Problem Description list expands to a full screen list if the user selects the arrows.
7. Select a problem in the list to fill the Problem description, ICD description, and ICD code fields.
   You can edit the Problem description field for a patient and problem, if required. This does not change the actual description because the ICD description field fills based on the ICD code associated with the problem. The ICD code field displays the last ICD code associated with the problem. The Active Medications label changes to Associated Medications.
8. Add or update information about the problem in the Notes, Plan Details, Patient Details, and Provider Details sections as required.
9. To open the Dx/AP History template, select Dx/AP History.
10. Select Add/Update.
    If the Problem description field is modified or different from the fully specified name, an indicator , appears adjacent to the description field. The Fully Specified SNOMED Description can be viewed by pausing the mouse pointer over the indicator.
    The information entered or updated in the template appears in the Today's Assessment grid.

    The Problem description added on the Chronic Conditions template also appears in the Clinical Problems grid on the Add or Update Assessment template.

11. Select the Medical Chart Summary panel to select and view the details documented by the Intake staff and provider in the encounter.
12. Select the Care Guidelines panel to document information about the health maintenance and chronic diseases.
13. Select the Orders panel to create orders for lab, diagnostics, and so on.
14. Select Save & Close.