Patient Encounter Documentation

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Documenting Patient Encounters for the Family Practice Visits

You can document patient encounters for a family practice visit. You can document the Family Practice office and virtual visits on the following templates: Intake Histories SOAP Finalize Checkout Using the Intake and Histories templates, a nurse or medical assistant can document the reasons for visit, medications, allergies, social histories, and so on. Provider uses the SOAP and Finalize templates to document assessment and physical exam details, generate evaluation and management codes, and so on. The front desk employees use the Checkout template to view order details and provide necessary documents to the patient. Before you document a standard visit, you can configure optional settings to quickly open templates and features. Some of the common configurations associated with templates are setting up task recipients, new navigational links, links in the navigation bar, and reasons for visit. Some of the common features available in a standard visit template set are the Patient Infor

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Encounters for Family Planning Visits

You can use the NextGen® Adaptive Content Engine templates to document encounters for the family planning visit type. You can use the following templates to document the family planning office visit workflow: Intake Histories SOAP Finalize Checkout Before you begin documenting the family planning office visit, you can pre-configure certain optional settings for quick access of some templates and features. The Basic Configuration and Setup Procedures section includes instructions to set template preferences, add the required navigational and sub-navigational links, configure task recipients, and customize the reasons for visit. The General Office Visit Workflow section explains some of the common features such as patient information bar, panel control, pre-visit planning template updates, and so on, available in the Family Planning Office Visit template set. The Intake Workflow section provides instructions for nurse or medical assistant on how to use the Intake and Histories templates

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Getting Started

NextGen® Adaptive Content Engine templates enable you to document patient encounters on the visit types associated with the available specialties. You can also configure new links, navigation bar, reasons for visit, set up default templates, preferences, and so on. Patient Encounter Documentation You can use NextGen® Adaptive Content Engine templates to document patient encounters on the visit types associated with the specialties available. Managing Basic Configuration Before you begin, you can configure some optional settings such as template preferences, template links, and so on. Managing Basic User Interface Functionality Accessing and Setting up Templates from Navigation Bar You can access and configure various templates in the Navigation bar. General Office and Virtual Visit Workflow You can find general and virtual visit workflows in the Intake and Histories template.

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

Gastroenterology Office and Virtual Visit

You can document the encounter details of a gastroenterology patient on various templates. You can use NextGen® Adaptive Content Engine to document patient encounters in the gastroenterology specialty. The gastroenterology office and virtual-visit workflows are documented on the following templates: Intake Histories SOAP Finalize Checkout The general office and virtual-visit workflow includes the following: The intake staff workflow provides instructions for nurses or medical assistants on how to use the Intake and Histories templates to document the reasons for visit, medication, allergies, social history, and so on. The provider workflow provides instructions for providers on how to use the SOAP and Finalize templates to document assessment and physical exam details, generate evaluation, management codes, and so on. The checkout staff workflow provides instructions for front-desk employees on how to use the Checkout template to view order details and provide necessary documents to pa

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Cardiology User Guide

You can document the Cardiology visits on the following templates: Intake Histories SOAP Finalize Checkout Intake Staff Workflow The intake staff, such as a nurse or technician, can use the Intake template to document patient encounter workflow. The intake staff opens the visit by checking the patient in, using the Intake template. The intake staff can review the patient's details documented in the previous encounters on the Home Page template. Histories Workflow After documenting the details on the Intake template, the nurse can document the medical history of the patient on the Histories template. Provider Workflow After the nurse documents the intake and medical details, the provider can document assessments and findings, and submit the codes for billing. The provider can review the patient's historical information documented in the previous encounters on the Home Page template or review the Intake Note document generated by the intake staff. The provider documents the patient exami

Patient Encounter Documentation

Recommendations

Documenting Patient Encounters for the Family Practice Visits

Document Encounters for Family Planning Visits

Getting Started

Review of SOAP Details by Provider

Gastroenterology Office and Virtual Visit

Cardiology User Guide

Patient Encounter Documentation

Documenting Patient Encounters for the Family Practice Visits

Document Encounters for Family Planning Visits

Getting Started

Review of SOAP Details by Provider

Gastroenterology Office and Virtual Visit

Cardiology User Guide