Histories Template

Table 1.
Section	Description
Problem List	You can view, add, modify and retrieve patient's clinical problems and chronic conditions.
Medical/Surgical/Interim	You can document the patient's problem list and social, medical or surgical, diagnostic study, and family histories.
Diagnostics Studies	You can document the patient's diagnostic tests and its associated results.
Family	You can document the family history of the patient.
Social	You can document the social history of an adult or a pediatric patient. The categories in the social history includes tobacco/vaping use, alcohol/caffeine, lifestyle, occupation and so on.

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Documenting Social Details of Pediatric Patients

You can document social details of a pediatric patient in the Social panel. Section Description Tobacco/Vaping Use You can document the passive smoke exposure details of a pediatric patient. Relationships You can document child care provider details and relationship information of the patient. Home Environment You can document the patient's home environment and safety information. Education You can document the patient's education, sleep, activities, and any recent travels details. Nutrition/Elimination You can document the patient's nutrition, elimination, body image and dental care information. Comments You can add your comments or additional information related to pediatric social history. For comprehensive documentation of the patient's nutrition details, the following templates open based on the patient's age: Interval History - Nutrition birth- 12 mo for 0 to 12 months Interval History - Nutrition 1 to 4 yr for 1 to 4 years Interval History Nutrition Over 5 yr for 5 years or olde

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

Document the History Review

You can document the review details of a patient's history in the generated encounter document. You can also document the review status of medical, surgical, family, and social histories on the template. Open NextGen® Enterprise EHR. On the Histories template, select the History Review link.The History Review template opens. In Med/Surg/Interim Hx, Family, and Social, select the applicable option. Detailed document allows you to view all the details entered in the Histories template in the encounter document. Reviewed, updated allows you to indicate that you have reviewed and updated the patient's histories. Reviewed, no changes allows you to indicate that you have reviewed the patient's histories but made no changes. History unobtainable allows you to indicate that the information is not obtainable and enter the reason in the corresponding field. Select Save & Close. Note: Each reviewed area (Med/Surg, Family, and Social Histories) contributes to the Evaluation and Management coding.

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Histories Template

You can add, update, delete, and review a patient's history summary details. The Histories template enables you to document a patient's social history, problem list, medical or surgical history, diagnostic study history, and family history. You can also add skin cancer details. Documenting a Patient's History Summary You can add, update, delete, and review a patient's history summary details from the History Summary panel. Patient's Problem list Patient's Diagnostic Tests and Results You can document a patient's diagnostic tests and the associated results. Generate the Intake Note You can generate the intake note for a patient using Generate Intake Note in theIntake and Histories template. Document the History Review You can document the review details of a patient's history in the generated encounter document. Parent topic: Intake Staff Workflow

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

Patient's Social History

You can document a patient's social history. You can open the individual social history template or the Adult Social History template to document the social history information of a patient. The Adult Social History template includes the existing social history templates arranged in a one-page panel format. Each panel includes the data fields from the respective social history template. You can choose to document the social history information of the patient on individual social history templates or on the Adult Social History template. You can document the following social information for an adult patient on the social history templates or the Adult Social History template: Tobacco/Vaping Use Alcohol/Caffeine Statuses Lifestyle Occupation Comment Diet History Environmental Note: NextGen® Adaptive Content Engine is packaged with the individual social history templates as the default social history templates. However, the practice can configure the Practice Configuration template to set

Histories Template

Recommendations

Documenting Social Details of Pediatric Patients

Histories Template

Document the History Review

Histories Template

Documenting a Patient's History Summary

Patient's Social History

Histories Template

Documenting Social Details of Pediatric Patients

Histories Template

Document the History Review

Histories Template

Documenting a Patient's History Summary

Patient's Social History