Documenting Obstetric Patient Histories

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Overview of the Histories Template

You can add, update, delete, and review a patient's history summary details. You can document a patient's social history, problem list, medical or surgical history, diagnostic study history, and family history on the Histories template. Patient's Problem List You can manage a patient's problems. Patient's Medical History The Medical/Surgical/Interim panel allows you to document the medical or surgical history of the patient. Patient's Social History You can document a patient's social history. Patient's Family History You can document the family history of the patient in the Family panel on the Histories template. Patient's Diagnostic Tests and Results You can document a patient's diagnostic tests and the associated results. Document the History Review You can document the review details of a patient's history in the generated encounter document. Intake Note Generation You can generate Intake notes on the Intake template after all the intake activities are complete. View a Patient's Ap

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Histories Template

Patient history information is documented on the Histories template for a new patient, and reviewed and updated for an existing patient. Histories Patient's Problem List You can manage a patient's problems. Patient's Medical History The Medical/Surgical/Interim panel allows you to document the medical or surgical history of the patient. Patient's Diagnostic Tests and Results You can document a patient's diagnostic tests and the associated results. Patient's Family History You can document the family history of the patient in the Family panel on the Histories template. Document the Patient's Social History on Tobacco Usage You can document a patient's social history on tobacco usage in the Social History - Tobacco template. Parent topic: Physical Therapy

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Cardiology Histories Workflow

You can document the cardiology histories in the Histories - Cardiology template. The template uses standard framework functionality and is used by the nurse/technician to document a patient's history. You can document the following in the Histories – Cardiology template. Problems Medical/Surgical/Interim Diagnostic Studies Family Social Document Cardiac Problems The Problems panel enables you to document, search for, and select the chronic and secondary conditions of a patient's problems. Manage Patient's Disease You can manage the patient's disease in the Medical/Surgical/Interim panel on the Histories template. Update Past Medical History You can update the past medical history for a patient in the Edit Past Medical History template. Document the Interim History You can document all patient medical encounters, which includes but is not limited to, hospitalizations, emergency room visits, office visits, and same day surgeries. Document Historical Diagnostic Studies You can enter hist

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Documenting a Patient's History Summary

You can add, update, delete, and review a patient's history summary details from the History Summary panel. You can document a patient's history details in the History Summary panel in the following categories: Past Medical/Surgical Interim Social Family Diagnostic The History Summary panel also displays the patient history documented by the intake staff on the Histories template. You can add diagnostic studies with a documented Result or Interpretation to the grid in the Reason for Visit panel by selecting the Add to HPI Grid button. The grid includes a list of categories on the left pane to select and view the documented data. You can filter the patient history records by selecting the Medical History or Surgical History option for Past Medical/Surgical. You can view and enter confidential details provided by the patient during the course of the encounter using The Confidential link. You can select History Review to open the History Review template and select the applicable option to

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Obstetrics Histories Template

You can document information in the OB Histories template. The Histories template contains nine panels: Pregnancy History Gravidity/Parity Since Last Menstrual Period Medical/Infection History Medical/Surgical/Interim General Family Social Genetic Screening/Teratology Counseling The Histories template displays gravidity/parity, initial/working EDD, working EGA, blood type and Rh, and risk level as in Gestational Age template. After a complete history is taken, use the Risk Factors link to document the risk level. Note: When documenting risk factors, the practice may decide to only indicate the positive items rather than select negative for all of the remaining items. In addition, putting the actual risk level must be done by the provider. This may be done on this template or on the Prenatal Detail template. You may also use links to open additional templates, as needed: Demographics Order Management Document Library Chart Abstraction Note: Links are configurable by the practice and are

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Genetic Screening and Teratology Counseling Panel

You can document patient's genetic screening and teratology conseling information in the Genetic Screening/Teratology Counseling panel. On the Genetic Screening/Teratology Counseling panel, the answer to question #1 (whether the patient will be 35 years or older as of the due date) is selected by default. It can be manually changed, if needed. Open the Histories template. Open the Genetic Screening/Teratology Counseling panel. Select the Default All to No button. Note: .The option for patient will be 35 years or older as of the due date is selected by default based on patient's age. Ask the questions and change any answers to the Yes option, if appropriate. If any answers are positive, enter comments in the Comments/Counseling field, if needed. Note: Some items are general, or a combination of more than one thing, and require explanation. Select the Mother (patient), Father (baby's), and Relative (mother or father) checkbox, if required, or enter this information in the Comments/Counse

Documenting Obstetric Patient Histories

Recommendations

Overview of the Histories Template

Histories Template

Cardiology Histories Workflow

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Obstetrics Histories Template

Document the Genetic Screening and Teratology Counseling Panel

Documenting Obstetric Patient Histories

Overview of the Histories Template

Histories Template

Cardiology Histories Workflow

Documenting a Patient's History Summary

Obstetrics Histories Template

Document the Genetic Screening and Teratology Counseling Panel