Document Physical Health History

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

BH - Psychiatric Evaluation

The Psychiatry Eval tab is designed to be a stand-alone template for a psychiatrist, nurse practitioner (NPP), or other Behavioral Health professional who is qualified to conduct and document an initial psychiatric assessment of the client. The information on the Psychiatry Eval tab overlaps with the data recorded on the Comp Assess tab. Of the 17 panels on the tab, only two (Physical Health History and Issues for Children/Adolescents) are not identical to the corresponding panels on the Comprehensive Assessment. If a Comprehensive Assessment was completed for this client prior to the Psychiatric Evaluation, much of the information is filled. It is important to note that medications can be prescribed during the psychiatric evaluation. The Behavioral health billing section is available at the bottom of the Psychiatry Eval and Progress Note tabs to submit billing codes. Some providers may want to use the SOAP tab to document additional elements of the physical exam. For more information

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Reviewing Patient History on SOAP

You can review and edit a patient's medical history in the History panel on the SOAP template. The following categories in the History panel provide the corresponding history details. Past Medical/Surgical Interim Social Family Diagnostic History Panel The Social Determinants of Health and PRAPARE® links appear based on the Practice Configuration practice template settings. For more information on these settings, go to NextGen Healthcare Success Community, and download the latest Practice Configuration Template User Guide for NextGen® Adaptive Content Engine. Review Patient's History Summary on SOAP You can review and update a patient's history summary documented by the intake staff during the previous encounters, in the History panel on the SOAP template. Adding Patient's History Summary on SOAP You can update the history details entered by the intake staff and add any additional history details in the History panel on the SOAP template. Parent topic: Review of SOAP Details by Provide

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Physical Exam Findings

You can document the complete physical examination details of a patient on the SOAP template. The One Page Exam link opens a gender-specific or a gender-neutral, one-page physical exam template. Based on the configuration in the Physical Exam panel of the Framework Content system template and the selection of the Enable Gender Neutral PE checkbox on the Practice Configuration template, the gender-specific or a gender-neutral, one-page physical exam template opens. For more information, go to NextGen Healthcare Success Community, and download the Framework Content System Template for NextGen® Adaptive Content Engine and Practice Configuration Template User Guide for NextGen® Adaptive Content Engine. Open NextGen® Enterprise EHR. On the SOAP template, expand the Physical Exam panel. Select One Page Exam. The One Page - Physical Exam template opens. One Page - Physical Exam Document your findings on the template. Note: To save the documented value as the default set, you can select the Qu

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Review a Patient's Symptoms for Various Systems

As part of the provider workflow, you can review and update symptoms entered during the patient's intake. Open NextGen® Enterprise EHR. Open the SOAP template, and then expand the Review of Systems panel. To select a default set of findings, select an appropriate value in ROS Defaults. Note: You can also select Load to quickly load any saved review of systems, or select Save to save the documented review of systems to use them on other encounters. To document symptoms for multiple systems on a single template, select One Page ROS from the left navigation bar. Note: You can configure the One Page ROS link to open a gender-specific or gender-neutral template by using the Framework Content template. You can also customize the label for the One Page ROS link. To document findings for a single system, select an appropriate link from the left navigation bar. To copy review of systems from a previous encounter to the current encounter, select ROS History.If you have copied and edited informat

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Patient's Physical Exam

You can examine a patient and document the associated information using the Physical Exam panel that displays a list of exam categories. The links that appear are configurable by specialty or by provider. The Physical Exam panel displays the system name, followed by exam findings, and the details. On Physical Exam, you can use the One Page Exam link in the left pane to open the One Page-Physical Exam template, which enables you to document the complete physical exam details on a single template. You can also document a single system exam. Physical Exam panel You can select the Office Diagnostics button to open the Office Services template to view or enter the various diagnostic tests and results. You can configure the physical exam systems in the Framework Content system template. Based on the configuration, the systems appear on Physical Exam of SOAP. For more information on configuring the systems, go to NextGen Healthcare Success Community, and download the Framework Content System

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Copy Physical Exam Findings from Previous Encounters

You can copy physical exam findings from previous encounters of a patient to the current encounter instead of manually adding them. Open NextGen® Enterprise EHR. Open the SOAP template, and then expand the Physical Exam panel. Select Physical Exam History.The Historical Information window opens. Note: The records are displayed for the default duration configured in the Copy Previous Visit Information section of the Practice Configuration template. For more information, go to NextGen Healthcare Success Community, and download the Practice Configuration Template User Guide for NextGen® Adaptive Content Engine. To filter the records in the grid, enter the search criteria in Filter by, and then select Search. Note: If the records are displayed from any sensitive encounter, an asterisk (*) appears on the record in the Sensitive column to help you decide whether to copy such records and update the current encounter as sensitive. Select the record to copy, and then select Copy Physical Exam &

Document Physical Health History

Recommendations

BH - Psychiatric Evaluation

Reviewing Patient History on SOAP

Document Physical Exam Findings

Review a Patient's Symptoms for Various Systems

Patient's Physical Exam

Copy Physical Exam Findings from Previous Encounters

Document Physical Health History

BH - Psychiatric Evaluation

Reviewing Patient History on SOAP

Document Physical Exam Findings

Review a Patient's Symptoms for Various Systems

Patient's Physical Exam

Copy Physical Exam Findings from Previous Encounters