Document Therapy and Treatment Orders

The Therapy Orders template enables you to enter detailed information about prescribed therapy and treatment orders for the patient including the diagnosis, treatment type, physician goals and the number of authorized visits.

1. Open NextGen® Enterprise EHR.
2. To open the Therapy Order template, do one of the following:
   • In the navigation bar, select Orders.
   • In the Assessment / Plan panel on the SOAP template, select Therapy Orders.
3. Select a diagnosis or an assessment in the Encounter Diagnoses or Treating Assessment section.
   Note: You can add or update the records in the Encounter Diagnoses or Treatment Assessment grids, if required.

   When you select a diagnosis in the Encounter Diagnoses or Treating Assessment grid, the diagnosis details appear in the corresponding read-only fields. You can select up to 4 diagnoses. It is mandatory to select a diagnosis for Dx1 field before placing an order. When you place an order, the selected treating assessments and historic assessments are added to the current encounter.
4. If applicable, in the Surgical Procedure field, select a surgical procedure in the Select Procedure search tool and complete the remaining fields related to the surgical procedure including the Procedure Date and Precautions or Contraindication.
5. Select the applicable check boxes in Treatment, Physician Goals, Referred, Therapy, Modalities, Spine Rehabilitation, Other, Education, and Splinting sections.
6. If applicable, in the Certification section, enter the following details for certified visits.
   • Select the From and Through dates.
   • Select the number of times each week the patient must have the treatment encounter in the Weekly frequency field.
   • Select the duration of the treatment in weeks or months in the Duration field.

   The system calculates the Number of Visits based on the weekly frequency and duration values.

   To indicate that a patient's visit can be scheduled when necessary, select PRN (Pro re nata).

7. Enter Comments manually or use the My Phrases link.
8. Select Place Order.
   A new record appears in the Therapy Orders grid.