Review of SOAP Details by Provider

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

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

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 Reasons for a Patient's Visit

You can review and update reasons for a patient's visit during the provider workflow. Open NextGen® Enterprise EHR. Open the SOAP, and then expand the Reason for Visit panel. Review and update the patient summary in the Introduction field. Review and update reasons for visit, diagnostic studies, and chronic conditions. To add any additional information, select Comments. Review Intake Comments on the SOAP Template Review comments entered during the intake if the Intake Comments link on the SOAP template indicates that content is present. Edit a Reason for Visit on the SOAP Template You can edit existing reasons for visits on the SOAP template. Add and Review Comments for the History of Present Illness You can review and enter additional comments for a patient's history of present illness (HPI). Remove a Studies Reviewed on SOAP Template You can remove the historical diagnostic studies that are added to the history of patient illness in the Studies Reviewed section on the SOAP template.

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Documenting SOAP Information

Use the SOAP template to enter history, exam, assessment, and plan information. Reason for Visit on the SOAP Template You can use the Reason for Visit to enter the patient introduction and additional details about the reason for visit. Physical Exam Panel You can document physical exam details. Document Review of Systems Details You can review and update symptoms entered during the patient intake process in the Review of Systems section on the SOAP template. Review and Reconcile Allergies Review the Patient's Vital Signs Review Narratives on SOAP You can review and update the ambient-generated narrative text on SOAP. SOAP Link Icons The icons for various links appear on the SOAP template. Parent topic: Provider Workflow

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Review of Vital Signs on the SOAP Template

You can review and update a patient's vitals signs documented by the intake staff, in the Vital Signs panel on the SOAP template. You can add multiple vital signs for a patient during an encounter. The Vital Signs panel displays the most recent value for each vital sign. Options for Vital Signs The Add button opens the age specific vital signs template based on the patient age and the Pediatric Age configuration on the Practice Configuration template. For more information on the Pediatric Age setting, go to NextGen Healthcare Success Community, and download the Practice Configuration Template User Guide for NextGen® Adaptive Content Engine. Add Vital Signs on SOAP While examining a patient, you can add the patient's vital signs in the Vital Signs panel on the SOAP template. Edit Vital Signs You can edit the vital signs details entered during the intake process, in the Vital Signs panel on the SOAP template. Parent topic: Review of SOAP Details by Provider Parent topic: The Provider Wor

Review of SOAP Details by Provider

Recommendations

The Provider Workflow

The SOAP Template

SOAP Template

Review Reasons for a Patient's Visit

Documenting SOAP Information

Review of Vital Signs on the SOAP Template

Review of SOAP Details by Provider

The Provider Workflow

The SOAP Template

SOAP Template

Review Reasons for a Patient's Visit

Documenting SOAP Information

Review of Vital Signs on the SOAP Template