Document the Patient's Report and Recovery Details
Do one of the following:
Select
Report received from
and select a provider/clinician from the list.
Select the upper-blank row in the list and enter the appropriate user name in the
Report received from
field.
Note:
The list from the
Report received from
field allows you search the provider by typing the first three letters of the last name.
The system fills the
Recovery admission time
field automatically with the current time.
Select the clock
to display the current system time.
Select the drop-down arrow to open the
Time Entry
template.
The
Time Entry
template allows you to enter the exact recovery admission time in hours, minutes, and seconds.
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Document the Patient's Report and Recovery Details
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
General Panel on the ASC - Postprocedure Template
The General panel is used to document the physician or clinician name who submitted the report and recovery admission time. General Panel The Allergies link opens the Allergies module to document the allergies details. The Medications link opens the Medications module to enter patient's medication details. For information on the Medications module documentation, see Medications Module. Document the Patient's Report and Recovery Details Parent topic: ASC - Postprocedure Template
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Use the General Panel on the ASC - Scheduling Questions Template
You can document general information on the procedure using the General panel. The General panel includes fields such as scheduled date and time of the procedure, location where the procedure is to be performed, and the rendering provider, specialty physician, and/or anesthesia provider involved during various stages of procedure. Select the Established patient or New patient option. General Panel If applicable, select the Historian field and select the historian providing the information on the patient's medical condition. Select the following fields and select appropriate providers from the corresponding list: Rendering provider Primary specialty physician Anesthesia provider To clear the values from the provider fields, double-click the blank space in the respective list. Note: The list that opens from the Anesthesia provider field allows you to search for the provider by typing the first three letters of the last name. You can select the top-blank row in the list and enter the appr
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
General Panel on the ASC - Intake Template
The General panel allows the nurse to document provider details and scheduled date and time of procedure. This panel includes the Patient check-in time field to enter the time when the patient arrives at ASC, and the Admission time field to enter the time when the patient was taken to the ASC suite. You can select the drop-down arrow to open the Time Entry template and enter the exact time in Hour, Minutes, and Seconds, or you can select the clock next to the time fields to input the current system time. For information on the General panel documentation, see General Panel on the ASC - Scheduling Questions Template. General Panel If the case ID of the encounters is the same, the details documented in this panel on the ASC - Scheduling Questions template or on the ASC - Pre admission template carry forward to the General panel on the ASC - Intake template. Document the Interpreter Details You can document the answers for the preconfigured questions. Document Configurable Questionnaires
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document the IV Removal Details
Highlight a row of IV insertion record in the grid. Select Edit to open the ASC IV template. If the IV is removed, do the following in the Removal section: Select the drop-down next to the Removal time field. The Time Entry template opens. Note: The Removal time field is available to document only when the IV insertion attempt is Successful. Enter the time when the IV was removed and select OK. The documented time appears in the Removal time field. You can select the clock to enter the current system time. The Removed by field appears with the current user name. Select Removal site condition and select the condition(s) of the IV site after removing the IV. Select Close on the list. Select Reason for Removal and select a reason from the list. If appropriate, select Removed by and select the nurse or medical assistant who removed the IV from the patient. If applicable, enter or update comments in the Comments field. The left and the right arrows are used to go to the previous or the next
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter Assessments, Adverse Events, and Quick Notes for the Procedure
The ASC Documentation Log template allows you to document patient's assessments, routine quick notes, any adverse events that occurred during the procedure, and the nursing diagnosis and nursing assessments initiated for the patient. This template is configured on the Documentation Log Config practice template. For more information on the configuration of the navigational tabs, entry type, categories/sub-categories, and descriptions on the ASC Documentation Log template, go to NextGen Healthcare Success Community, and download Documentation Log Config Practice Template for NextGen® Adaptive Content Engine. The ASC Documentation Log template has a dynamic flow that displays additional content after each selection. As the flow progresses, you may need to select the navigation tabs above the grid to enter additional content. From the Documentation Log panel, select Add to open the ASC Documentation Log template. ASC Documentation Log The Procedure field displays the procedure selected in
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Open the Templates Associated with Procedure Post Discharge Visit Type
The Procedure Post Discharge visit type of the Ambulatory Surgery specialty allows you to document the post discharge details. Open NextGen® Enterprise EHR. To open the Templates module on a patient encounter, do one of the following: On the Categories or Encounter History tab, select Open Template. On Top Toolbar, select Templates. On the main menu, select File > New > Template. The Select Template window opens. In the Show section, select the All option. Select Home Page from the list of Medical Records templates. Select OK.The Home Page template opens. Select the Specialty list and select Ambulatory Surgery from the list. A list opens to select visit type. Select Procedure Post Discharge from the picklist. The Home Page - Ambulatory Surgery template opens. In the Home Page - Ambulatory Surgery template, you can view the data documented by the provider or nurse on the Procedure visit type and Procedure Preadmission visit type. To proceed with the Procedure Post Discharge visit, selec
to display the current system time.
