Documenting Office Procedures

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Documenting Assessment Details

You can add or update a patient's assessment details in the Assessments tab. You can update the ICD-10 coding and 5010 standards using the patient's assessment. You can select the assessment details in the grid and submit the first 12 diagnoses for claim processing. You can add or update an assessment in the following sections: Billing Diagnosis History Clinical Problems My Favourites The Today’s Assessments grid on the Assessments tab contains the following details: First column displays the priority, considering that you can submit only the first 12 row items for claims. Second column displays the diagnosis description, diagnosis code, and if entered, the status, side, and site details. Third column displays the differential diagnoses. Note: If an HCC column appears in the grid, the practice administrator must turn on the Hierarchical Condition Category (HCC) coding functionality in the Problems module. For more information, go to NextGen Healthcare Success Community, and download th

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

My Plan Template

You can view existing details or add a new entry in the Medications and Immunizations module using the plan-type template. My Plan Template Set You can document the patient's diagnosis, lab orders, plan details, referrals, medications, and immunization details using the My Plan template. Documenting Assessment Details You can add or update a patient's assessment details in the Assessments tab. Documenting Custom Plans You can document diagnosis, lab orders, plan details, referrals, medications, and immunization details for a patient using the My Custom Plan 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. Documenting a Patient's Lab Order Details You can place lab orders for the patient's assessments using the Lab Master template or the Orders console. Documenting Diagnostic Studies You can order a diagnostic study on the Diagnostic Studi

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document an Office Procedures Order

You can document point of care tests for a patient in the Office Procedures template. 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. The My Plan window opens. Select the Office Procedures tab.The Office Procedures template window opens. Select an assessment from the Today's Assessments grid.The diagnosis details linked to the assessment appear in the corresponding fields. You can update them as required. Note: You can select Add or Edit to update the assessment details. Select a point of care test.The office service details appear in the corresponding fields. You can update them as required. To indicate that an injection, IV fluid, or medication was required, select the associated option. Select Place Order. Note: If ordering medications from the My Plan template, the drug interaction and allergy check is performed upon placi

NextGen® Orthopedic Suite Help 80.2.14.0

Add Procedures for Orders

You can add procedures to order radiology tests, therapies, durable medical equipment (DME), lab tests, and referrals. Open any applicable template, and then select Dx & Px. The Diagnoses & Procedures window opens. Note: The procedures from all encounters of the patient appear in the Procedure History grid. Select Orthopedic Procedure History or All Procedure History. To associate a procedure with the order, double-click it in the Procedure History grid. The selected procedure is added to the Procedures grid. Note: To remove a procedure, you can select it from the Procedures grid. Select Close. Parent topic: Order Tests, Therapies, Equipment, and Referrals in the Single Order Template Related tasks Order Therapies in the Therapy Order Template Add a Surgical Procedure Manage Surgical History of Patients

NextGen® Orthopedic Suite Help 80.2.14.0

Order Tests, Therapies, Equipment, and Referrals in the Single Order Template

You can document the details of radiology, therapy, lab, durable medical equipment (DME), and referral orders required for a patient and place all orders at once. Open the Home or any other applicable template, select Orders from the upper navigation bar, and then select Single Order. Select Dx & Px to add the necessary diagnoses and procedures. Selecting procedures is optional; however, you must add at least one diagnosis to order external radiology tests, therapies, durable medical equipment (DME), lab tests, and referrals. Note: You can use the Radiology Picklists panel in the Radiology Configuration template to make diagnosis-code selection mandatory for placing internal radiology test orders, depending on the category. For more information, go to NextGen Healthcare Success Community, and download latest Configuration Guide forNextGen®Orthopedic Suite. Do one of the following: To document the order details from quick picks, select the provider set or system set icon. Note: Quick pi

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Orders

You can add and manage the orders for a patient. You can view, process, manage, add, and place a follow-up order from the Orders panel. It also includes links to process lab and radiology orders, open the Order Management template, open the Immunizations template, open standing orders on the Office Services template, create tasks on the To Do template, and document the education provided to a patient. Orders Panel The View All Orders link is selected by default. The other options to view include Labs, Diagnostics, Office Services, Immunizations Today, Surgical Procedures, Referrals, and Patient Education. You can select a row in the grid and select Edit to open the Orders Edit template, and update the order details. The Education material provided section allows you to provide patient education documents and indicate if they are provided in the patient's preferred language and FDA-approved. The patient education options appear in the section based on the availability of family planning

Documenting Office Procedures

Recommendations

Documenting Assessment Details

My Plan Template

Document an Office Procedures Order

Add Procedures for Orders

Order Tests, Therapies, Equipment, and Referrals in the Single Order Template

Orders

Documenting Assessment Details

My Plan Template

Document an Office Procedures Order

Add Procedures for Orders

Order Tests, Therapies, Equipment, and Referrals in the Single Order Template

Orders