Documenting SOAP Information

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

SOAP Template

You can review and modify the documented patient intake and histories information on the SOAP template. You can review the Asthma Flowsheet, Allergy Test Flowsheet, Spirometry, and Nebulizer panels. You also can document physical exam, assessment plan, and communication details. SOAP Link Icons The icons for various links appear on the SOAP template. Document the Patient's Reason for Visit as a Provider The reason for visit added by the intake staff on the Intake template appears on the SOAP template. Patient's History Summary Documentation by Provider You can document a patient's past medical or surgical history, interim, social, family, and diagnostic study history in the History Summary panel. Document Vital Signs The provider reviews the vital signs added by the Intake staff on the Intake template and makes the applicable changes. Patient's Physical Exam You can examine a patient and document the associated information using the Physical Exam panel that displays a list of exam cate

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Review of SOAP Details by Provider

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, assessment plans, and provider communications. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan Narrative notes You can select the Record contains substance use disorder information checkbox on the SOAP template header to include the long or short form of disclosure for Substance Abuse and Mental Health Services Administration (SAMHSA) 42 CFR Part 2 provisions in the generated documents and reports. You can use Quick Notes to save the documented SOAP findings as a default set that can be used in future encounters. For more information on these settings, go to NextGen He

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Provider Workflow

You can review the patient's medical summary details on the Home Page template and then proceed to the SOAP Plan Finalize templates. The provider workflow involves: Reviewing the data documented up to this point in the encounter to obtain an overview of the patient's condition as well as updating and providing additional information as needed Documenting the presenting problem(s) and various physical exam findings Documenting the procedures performed Creating a treatment plan Documenting Evaluation and Management (E & M) codes Patient Tracking in the Provider Workflow You can update the patient tracking details using the Patient Tracking on the Patient Information Card (PIC). Review of Intake Details by Provider You can start the visit by reviewing the patient's details entered by the intake staff on the Home Page template, to determine if any updates should be made. Review of SOAP Details by Provider You can review and modify the patient’s reasons for visit, review of systems, and vit

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

The Provider Workflow

You can review the patient's medical summary details on the Home Page template, and then open the SOAP and Finalize templates. The gastroenterologist provider workflow involves the following: Reviewing and updating the documented by the intake staff during the patient encounter and providing any additional information. Documenting problems and various physical examination findings. Documenting performed procedures. Creating a treatment plan. Documenting Evaluation and Management (E&M) codes. The E&M coding and sign-off functionalities are available on the Finalize template. Patient Tracking in the Provider Workflow You can update the patient tracking details using the Patient Tracking on the Patient Information Card (PIC). Review of Intake Details by Provider You can start the visit by reviewing the patient's details entered by the intake staff on the Home Page template, to determine if any updates should be made. SOAP Template You can review and modify the patient’s reasons for visit,

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

SOAP Template

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, history, and plan information. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan Narrative notes Although the you could enter the reason for visit and HPI on the Intake template, there are options available on the SOAP tab that are not available on the Intake tab. Parent topic: The Provider Workflow

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

The SOAP Template

You can use SOAP to review the patient information gathered during intake and to document the exam, assessment, and plan. On the SOAP template, you can review the patient's visit type, messages, and risk indicators. You can indicate if the patient is new or established for the current encounter on the header of the SOAP template. You can also review or document the following: General information Reason for visit History summary Review of systems Vital signs Physical exam Assessment and plan Parent topic: Review of SOAP Details by Provider Parent topic: Provider Workflow See also Reviewing Patient History on SOAP Review a Patient's Symptoms for Various Systems Review of Vital Signs on the SOAP Template Document Physical Exams Document Assessments and Plans

Documenting SOAP Information

Recommendations

SOAP Template

Review of SOAP Details by Provider

Provider Workflow

The Provider Workflow

SOAP Template

The SOAP Template

Documenting SOAP Information

SOAP Template

Review of SOAP Details by Provider

Provider Workflow

The Provider Workflow

SOAP Template

The SOAP Template