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Enter Assessments, Adverse Events, and Quick Notes for the Procedure

The ASC Documentation Log template allows you to document patient's assessments, routine quick notes, any adverse events that occurred during the procedure, and the nursing diagnosis and nursing assessments initiated for the patient. This template is configured on the Documentation Log Config practice template. For more information on the configuration of the navigational tabs, entry type, categories/sub-categories, and descriptions on the ASC Documentation Log template, go to NextGen Healthcare Success Community, and download Documentation Log Config Practice Template for NextGen® Adaptive Content Engine.

The ASC Documentation Log template has a dynamic flow that displays additional content after each selection. As the flow progresses, you may need to select the navigation tabs above the grid to enter additional content.

  1. From the Documentation Log panel, select Add to open the ASC Documentation Log template.
    ASC Documentation Log

    The Procedure field displays the procedure selected in the Documentation Log panel.

    The current system time the Time field.

  2. To select a different procedure, do one of the following:
    • Select the Procedure field and select a procedure from the list.
    • Select the left blue arrow or right blue arrow to go to the previous or next procedure respectively.
  3. To modify the time of the entry, do one of the following:
    • Select the drop-down arrow to open the Time Entry template and enter the time.
    • Select the clock , to display the Time field with the current system time.
    • Select Late Entry and enter the Reason the entry is recorded at a later time than when it occurred.
  4. Select an Entry Type from the grid.
    The Category tab and a list of categories appears.
  5. Select a category from the grid.
    If the selected category includes sub-categories, then the sub-category list appears.
  6. (Optional) Select a sub-category from the grid.
    A list of descriptions associated with the selected category or sub-category displays.
  7. Do one of the following:
    • Select a description in the right grid.

    • Select Custom value to enter appropriate description in the field and select OK.

      The entered description appears in the right grid replacing the Custom value verbiage.

  8. Select the navigational tab and select the appropriate value.
    ASC Documentation Log

    You can multi-select descriptions associated with certain categories and/or sub-categories.

    An asterisk (*) appears, indicating that the value is selected.

  9. To remove a selection with an asterisk (*), you need to select the value again.
    The asterisk (*) disappears, indicating that value is no longer selected.
  10. Select the Add New button to save and clears the data in the template to document a new entry.
  11. Select Save & Close.
    The documented data appears in the grid in the Documentation Log panel. The comment concatenates in the corresponding Description column in the grid.
    Documentation Log

Enter Assessments, Adverse Events, and Quick Notes for the Procedure