Add Additional Past Medical History

You can document additional past medical history on the Past Medical History template.

1. Open NextGen® Enterprise EHR.
2. Open the Histories template.
3. In the Medical/Surgical/Interim panel, select Add.
   The Past Medical History template opens.
4. Select a condition in the Medical panel or a procedure in the Surgical panel to add to the patient's medical history.
   The Details icon, and the Date field appear next to the selected item on the Past Medical History template.
5. To enter additional information about a procedure or condition added to a patient's part medical history, select .
   The Manage Past Medical/Surgical History template opens.

   

6. For a group condition or procedure, to select a value, do one of the following:
   • Select a value from the list.
   • Select the search button and use the search window to locate and select an appropriate condition or procedure and the associated SNOMED code.
   NextGen® Enterprise EHR fills the SNOMED code for the Disease/disorder field or the Management field based on the medical or surgical selection.
   Note: For an individual condition or procedure, the Disease/disorder or the Management field is read-only.
7. Document information for a medical condition or surgical procedure as follows:
   • Medical Condition:
     • Enter the appropriate information in the Onset date, Onset age, and Side fields.
     • If applicable, enter a value in the Management field.
       Note: You can also select the blue arrow to select the procedure from the picklist or select the search button to search and select the Management value and the associated SNOMED code.
   • Surgical Procedure:
     • Enter the appropriate information in Date, Age, Side, Facility and Provider fields.
     • If applicable, enter a value in the Disease/disorder field.
       Note: You can also select the blue arrow to select the procedure from the picklist or select the search button to search and select the Disease/disorder value and the associated SNOMED code.
8. Select a procedure.
   NextGen® Enterprise EHR fills code associated with the procedure in the CPT field.
9. Select the Body site field to search and select the location of disease/disorder.
10. Select the Outcome field and select the value from the list.
11. Enter your comments.
12. Select Save to Grid & Close.
    The information appears in the Past Medical History grid on the template.