Document Physical Exam in the OB Postpartum Template

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Assessment and Plan in the OB Postpartum Template

You can document assessment and plan information in the OB Postpartum template. Select the Postpartum tab. Select the Physical Exam panel. Select the Add/Update button in the Assessment/Plan panel.The Add or Update Assessment template opens. Enter the applicable information in the Add or Update Assessment template.By default the ICD-10 code displays in the Assessment/Plan grid. The system assigns the ICD code to the Assessment field on the template. This code displays by default for the Visit Type of OB Postpartum and does not include Document Pregnancy Outcome which is typically done without the patient being present. Select Save & Close. To enter information in the Consent – Procedures template, select the Consent link. To generate the proc_consent document, select the Consent button. To enter information in the Procedure Scheduling link, select the Procedure Scheduling button. Select the CQM icon to display information for the CQM – Maternity Care – Post-Partum Follow-up and Care Co

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Reason for Visit in the OB Postpartum Template

You can enter information in the Reason for Visit panel on the OB Postpartum template. Select the Postpartum tab. Open the Reason for Visit panel. Enter any additional text in the Introduction field.The Introduction field automatically displays a statement describing the patient's age, gender, and reason for visit. The same statement appears on the Reason for Visit panel of the SOAP template. To view the nurse or medical assistant's comments, select the Intake Comments link to open the Intake Comments template. Do one of the following: Select the postpartum check reason for visit from the left pane. Select the Additional / Manage link, and then select the postpartum check option in the Reason for Visit template. Open the Postpartum Details – HPI template and enter the required information. To enter information in the Diagnostic History Entry template, select Diagnostics. To view the chief complaint and reason for visit in the Hopi Notes template, select Comments. Document Postpartum De

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Obstetrics Postpartum Visit

You can document the OB Postpartum Visit template by using the Postpartum tab. You can document a routine OB postpartum visit using the OB Postpartum Visit template. You can document the routine OB postpartum visit without navigating to other templates, using the OB Postpartum Visit template . You can easily open any additional templates directly from the OB Postpartum Visit template. Wherever possible, the OB Postpartum Visit template fields maps to their corresponding fields in the other templates. The Postpartum template contains the following seven panels: General Reason for Visit Pregnancy Outcome Vital Signs Physical Exam Assessment/Plan Return Appointment Postpartum template Enter Information in the OB Postpartum Visit Template You can enter information in the OB Postpartum Visit template. Document Reason for Visit in the OB Postpartum Template You can enter information in the Reason for Visit panel on the OB Postpartum template. Document Pregnancy Outcome in the OB Postpartum T

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document a Physical Exam

The One Page Exam template is used to document a physical exam. Physical Exam panel You can examine a patient and document the information in the Physical Exam panel on the SOAP template. In the Physical Exam panel, you can do the follwing: Use the One Page Exam to document the exam on the Gyn-PE template. On the Gyn-PE select the Normal checkbox to indicate normal findings for each system or click the Findings field to add any abnormal findings. Use other single system exam and its sub menu in the left pane to document the corresponding exam details. When you click the single system exam or its sub menu, the respective template opens. Use the Office Diagnostics button to document or review diagnostics and to place orders for the tests. Use the Quick Load or Quick Save button to load a saved default set or save a new default set. Use the Physical Exam History button to copy previous physical exam records to the current encounter. Document a Breast Palpation Physical Exam You can docume

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

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. Open NextGen® Enterprise EHR. Open the SOAP template. In the Physical Exam panel, select One Page Exam. The One Page - Physical Exam template opens. Select the GYN Exam link. The GYN - PE template opens. GYN - PE To indicate normal findings for each system, select the Normal check box. To add any abnormal information, select the corresponding Findings field. In the STI Screenings section, select Yes for Pap. To document the Pap specimen collection, Select the Detail link. The Pap Detail-PE template opens. Pap Detail-PE Enter the necessary details in Pap Detail PE, and then select the diagnosis and type of Pap. 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

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Information in the Prenatal Visits Panel

You can document information in the Prenatal Visits panel for the current pregnancy. The Prenatal Visits panel contains a grid with data entered from all previous prenatal visits for the current pregnancy. The comments can be viewed in two ways. Open the Prenatal Visits panel. Select the row with an asterisk in the comments column, and view the full text of the comment in the Progress note field below the grid. Select the Progress Note Summary button.The Pregnancy Note Summary template opens. Select the OB Initial Exam link.The OB Initial Physical Exam window opens. Select the Default normal checkbox.All physical exam items up to the Adnexa item are marked as normal except for the Uterus size item. Any item that is not normal can be manually changed. Uterine size must be manually entered. Other exam items can be entered as needed. Note: If the initial exam is completed at the initial visit, the Lock (complete)initial physical exam checkbox indicating that the exam is complete can be se

Document Physical Exam in the OB Postpartum Template

Recommendations

Document Assessment and Plan in the OB Postpartum Template

Document Reason for Visit in the OB Postpartum Template

Document the Obstetrics Postpartum Visit

Document a Physical Exam

Document Pap Physical Exam Details for Annual Well Women Visits

Document Information in the Prenatal Visits Panel

Document Assessment and Plan in the OB Postpartum Template

Document Reason for Visit in the OB Postpartum Template

Document the Obstetrics Postpartum Visit

Document a Physical Exam

Document Pap Physical Exam Details for Annual Well Women Visits

Document Information in the Prenatal Visits Panel