Document the Asthma Flowsheet

You can document the diagnosis and clinical assessment for a patient on the Asthma Flowsheet template.

1. Open NextGen® Enterprise EHR.
2. Open a patient's record, and then open an encounter.
3. On Top Toolbar, select Templates .
   The Select Template window opens.
4. Open the SOAP template, and expand the Reason for Visit panel.
   The Asthma HPI template opens.
5. Select Asthma Flowsheet.
   The Asthma Flowsheet template opens.

   

6. To add a diagnosis, do the following:
   1. Select the Asthma Diagnosis field.
      The Diagnosis Search window opens and displays the asthma diagnoses.
      

   2. Select an asthma diagnosis from the list.
   3. In the Status field, select a status from the list.
7. In the Clinical Assessment section, select Upload Vital Signs to fill the fields with previously recorded vital signs or enter the values manually as follows:
   1. For Height, enter a value in the in or cm field within the range of 12 to 119.88 inches and 30.48 to 304.5 centimeters.
      If you enter the height in the cm or in field, NextGen® Enterprise EHR fills values in the other field automatically.
   2. For Weight, enter a value in the lb or kg field within the range of 4.409 to 1543.3 pounds or 2.00 – 699.99 kilograms.
   3. Enter the pulse rate in the Pulse field within the range of 10 to 499.
   4. Enter the systolic and diastolic values within the range of 0 to 399.
   5. Enter the Peak flow within the range of 10 to 999.
   6. Select the Pre Treatment or Post Treatment option.
   Note: If the value entered is not within the range, a message appears to indicate that the value entered is out of range.
8. In the Patient completed an asthma assessment tool section, complete the following:
   1. Select Yes or No to indicate if the patient completed an asthma assessment tool.
   2. Enter # of symptom-free days in the last 2 weeks.
   3. Record # of emergency visits for asthma symptoms in the last 6 months.
   4. Enter # of exacerbations requiring oral systemic corticosteroids in the last 12 months.
   5. Record the daytime and nocturnal Frequency of asthma signs/symptoms over the past 2-4 weeks (not just with acute attacks).
   6. Record Frequency of acute attacks/exacerbation.
   7. Record Short-acting beta agonists: Puffs per day.
   8. Record Asthma severity assessment (Classification) based on the information collected, if the details are not already filled based on the values entered on the Asthma-HPI template.
   9. Select Depression screening to answer depression screening questions related to the impact asthma has on quality of life.
      Note: If necessary, complete the Patient Health Questionnaire (PHQ-9) for further depression symptoms.
9. In the Self-Management section, complete the questions with Yes, No or N/A.
10. In the Medical Therapy section, record the patient's Quick Relief Medications and Long Term Control Medications.
    Note: Medications recorded on the Asthma Flowsheet template do not upload to the Medications module. You must add all medications directly on the Medications module.
11. Add additional information in the Comments field.
12. Select OK.