Post-op Rapid Note Template

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Orthopedic Patient Encounters

The Orthopedics User Guide for NextGen® Adaptive Content Engine provides an explanation and instructions on how to use the NextGen® Adaptive Content Engine for Orthopedic office and virtual visit encounters, document physical exams, fracture care, and pre-operative and post-operative visits specifically for an Orthopedic patient. This document is intended for Orthopedic medical professionals, such as nurses, providers and office staff who are responsible for documenting and processing patient information. The Configuration Procedures section of this guide explains how to set up a default template for every encounter, modify the chief complaints that display in the Reason for Visit panel, configure the links on each tab, and select an alternative view for the Physical Exam data on the generated documents. The next three sections take you through a typical workflow for the intake staff, provider, and check out staff. While every practice will come up with its own workflow, the intake sta

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Orthopedic Pre-Op Visits

After documenting the fracture, casting, and strapping details, if the patient has to undergo surgery, physicians can document the pre-operative details in the Preop Visit template. The Preop Visit template enables physicians to record the health condition and recommend any tests or refer to any other doctor to make sure that the patient condition is stable before surgery. Document Orthopedic Pre-Op Visit Details Schedule a Surgery for Orthopedics Parent topic: Orthopedics

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Findings in the Post-op Rapid Note Template

To access the Post-op Rapid Note template, you need to select Orthopedics as the specialty and Post OP Visit as the visit type. In the SOAP template, click the Rapid Note link.The Post-op Rapid Note template opens. In the Surgical History panel, do the following: Click the Facility field and select a facility. In the Surgery Type field, click the Inpatient, Outpatient or Observation option to indicate the type of surgery. Click the Surgeon field and select the physician name. Click the Assistant field and select the assistant who assisted the surgeon during surgery. Click the Assessment field to access the picklist. Select an assessment and click OK. Note: If the patient's diagnosis/assessment is not added earlier, the diagnosis search window is displayed when you click the Assessment field to search for and select a diagnosis. Click the Procedure field.The Select Procedure window opens. Search a procedure and select a procedure from the search result, and then click OK. Click the Side

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Record Postoperative Concerns

You can document the type and date of postoperative complications if the patient goes through an unplanned re-operation, hospital readmission, or surgical site infection within 30 days of the operation. 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. Select the A/P Details tab and then select the Postoperative Quality Reporting link.The Postoperative Quality Reporting template opens. Postoperative Quality Reporting Select a search method for the initial surgical procedure. Note: You can add or remove codes from the Postoperative Quality Measures list on the Modify Service Category Information template in File Maintenance. For more information on how to manage service categories, go to NextGen Healthcare Success Community, and download the Office Diagnostics Setup and Management Practice Template for NextGen® Adaptive Content E

NextGen® Orthopedic Suite Help 80.2.14.0

Pre-Op Templates

Access the FC Past Med Hx Template You can access the FC Past Med Hx template from the Home template. Document Past Medical History for Fracture Care You can document the pre-operative information for fracture care of patients. Pre-Operative Visit for a Surgery You can document the details of the pre-operative visit for a surgery. Pre-Operative History and Physical Exams The Pre-op H&P template enables you to document the details of H&P exams and generate the H&P Note. Submitting Charges to Finalize a Visit You can enter the visit details, today's diagnoses, and procedures to submit charges and finalize visit. Parent topic: Using NextGen Orthopedic Suite

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Orthopedics

The Orthopedics User Guide for NextGen® Adaptive Content Engine provides an explanation of and instructions on how to use the NextGen® Adaptive Content Engine for Orthopedic office and virtual visit encounters, document physical exams, fracture care, and pre-operative and post-operative visits specifically for an Orthopedic patient. Orthopedic Patient Encounters Configuration Procedures Intake Staff Workflow The intake staff can use the Intake template to document a patient's chief complaint, vital signs, medications, allergies, standing orders, and various other findings. 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. Overview of the Finalize Template Workflow You can complete the encounter workflow using the Finalize template. Overview of the Checkout Staff Workflow You can review and generate documents of a patient's checkout process. Orthopedic Physical Exam Templates Joint Aspir

Post-op Rapid Note Template

Recommendations

Orthopedic Patient Encounters

Orthopedic Pre-Op Visits

Document Findings in the Post-op Rapid Note Template

Record Postoperative Concerns

Pre-Op Templates

Orthopedics

Orthopedic Patient Encounters

Orthopedic Pre-Op Visits

Document Findings in the Post-op Rapid Note Template

Record Postoperative Concerns

Pre-Op Templates

Orthopedics