Document Pap Physical Exam Details for Annual Well Women Visits

You can document the physical exam details of an annual-well-women visit with a Pap specimen obtained and sent to the lab.

1. Open NextGen® Enterprise EHR.
2. Open the SOAP template.
3. In the Physical Exam panel, select One Page Exam.
   The One Page - Physical Exam template opens.
4. Select the GYN Exam link.
   The GYN - PE template opens.

   

5. To indicate normal findings for each system, select the Normal check box.
6. To add any abnormal information, select the corresponding Findings field.
7. In the STI Screenings section, select Yes for Pap.
8. To document the Pap specimen collection, Select the Detail link.
   The Pap Detail-PE template opens.

   

9. Enter the necessary details in Pap Detail PE, and then select the diagnosis and type of Pap.
10. Select Save & Close.
    The Pap Detail-PE template closes.

    The Submit breast exam to Superbill check box is selected by default.

    Note: If a screening exam is performed, the system automatically submits the appropriate assessment and G-code when the Submit breast exam to Superbill check box is selected.

    

11. Select Save & Close.