Documenting Assessment Plan Details

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document an Assessment Plan

You can document patient plan and provider plan details for the patient's assessment. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. Open the Intake template, select the specialty as Family Practice and the visit type as Office Visit, and then select My Plan. Select the A/P Details tab.The Assessment Plan Details template opens. Select an assessment from the Today's Assessment grid.The existing assessment details appear in the corresponding fields. Enter the details or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections. To enter follow-up appointment and disposition information, select Follow Up. To document counseling educational details and factors, select the Counseling Details. To enter post-operative details, select Postoperative Quality Reporting. For more information on the associated quality measure, select Q. Select Save & Close. Document Follow-up Details Yo

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Open the Assessments Tab

You can open the assessment tab using Add or Update Assessment template. Open NextGen® Enterprise EHR. Open the SOAP template, then in the Assessment/Plan section, select Add Assessments.The Add or Update Assessment template set opens. Optional: From the Intake or SOAP template, select the My Plan, and then select Assesments.The Add or Update Assessment template set opens. Sorting Assessments You can update the order of the assessments for a patient in the Reorder Assessments template. Convert ICD Codes in the Billing History Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the Today's Assessment grid in theAdd or Update Assessment template. Documenting Assessment Plan Details You can document your impressions and comments, differential diagnoses, and patient or provider plan details for an assessment using the A/P Details tab. Links and Buttons on the A/P Details Tab You can document the A/P Details tab using the available links and buttons

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Add or Update Assessment Template

You can open the Add or Update Assessment template using the Assessments link in the My Plan template. The Add or Update Assessment template allows you to add and update assessments. Add or Update Assessment Grids in Add or Update Assessment Template You can add or update the assessment template. Open the Assessments Tab You can open the assessment tab using Add or Update Assessment template. Sorting Assessments You can update the order of the assessments for a patient in the Reorder Assessments template. Convert ICD Codes in the Billing History Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the Today's Assessment grid in theAdd or Update Assessment template. Documenting Assessment Plan Details You can document your impressions and comments, differential diagnoses, and patient or provider plan details for an assessment using the A/P Details tab. Links and Buttons on the A/P Details Tab You can document the A/P Details tab using the availab

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Links and Buttons on the A/P Details Tab

You can document the A/P Details tab using the available links and buttons. The following links are available on the A/P Details tab: Link Description Previous Patient Plan Opens the Plan Previous Comments template with a read-only grid containing details for the selected assessment Previous Provider Plan Opens the Plan Previous Comments template with a read-only grid containing details for the selected assessment Health Promotion Plan Opens a template of the same name to document CMS data Today's Orders is a display-only field with order-related data pulled from the My Custom Plan template for the selected assessment. The A/P Details tab also allows you to do the following: Element Description Assessment/Plan Expanded View option Saved diagnosis details appear in a grid format similar to how it appears on the SOAP template. Follow Up Opens the Follow-up/Disposition template to document information surrounding a required appointment or placement. To document follow-up details, see the

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Record Postoperative Concerns

You can document the type and date of postoperative complications if the patient goes through an unplanned re-operation, hospital readmission, or surgical site infection within 30 days of the operation. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. Open the Intake template, select the specialty as Family Practice and the visit type as Office Visit, and then select My Plan. Select the A/P Details tab and then select the Postoperative Quality Reporting link.The Postoperative Quality Reporting template opens. Postoperative Quality Reporting Select a search method for the initial surgical procedure. Note: You can add or remove codes from the Postoperative Quality Measures list on the Modify Service Category Information template in File Maintenance. For more information on how to manage service categories, go to NextGen Healthcare Success Community, and download the Office Diagnostics Setup and Management Practice Template for NextGen® Adaptive Content E

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Save the Documented Assessment Details

After you have completed documenting the patient's plan and associated details, there are different options for proceeding with the encounter. Open NextGen® Enterprise EHR. To document another assessment plan when you are still in the Assessment/Plan Details template, select a different diagnosis from the grid in Today's Assessment. To document any other data, select one of the following: The Save & Close button Any of the other tabs in the My Plan template set The Cancel button - if there is unsaved data, a confirmation alert appears: You have unsaved data, do you want to exit without saving?My Custom Plan Parent topic: Add or Update Assessment Template Parent topic: Open the Assessments Tab Parent topic: Document an Assessment Plan Parent topic: Enter Assessment Plan Details

Documenting Assessment Plan Details

Recommendations

Document an Assessment Plan

Open the Assessments Tab

Add or Update Assessment Template

Links and Buttons on the A/P Details Tab

Record Postoperative Concerns

Save the Documented Assessment Details

Documenting Assessment Plan Details

Document an Assessment Plan

Open the Assessments Tab

Add or Update Assessment Template

Links and Buttons on the A/P Details Tab

Record Postoperative Concerns

Save the Documented Assessment Details