Add an Assessment on the SOAP Template
You can enter assessment and plan details on the
Add Assessment
tabbed template.
Open
NextGen® Enterprise EHR
.
From the
SOAP
template, in the
Assessment / Plan
panel, select
Add/Update
.
The
Add or Update Assessment
tabbed template set opens.
Select an assessment.
Enter the
Status
,
Side
,
Site
,
Impression
, and
Differential dx
fields.
Select
Add/Update
.
The assessment is added to the
Today's Assessment
grid.
Select
Save & Close
.
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NextGen® Adaptive Content Engine Help Enterprise 8
Update an Assessment on the SOAP Template
Open NextGen® Enterprise EHR. On the SOAP template, in the Assessment / Plan panel, select an assessment you want to update in the grid. Select Add/Update. The Add or Update Assessment tabbed template set opens. Make changes to the assessment. Select Save & Close. Parent topic: Document Assessments and Plans
NextGen® Adaptive Content Engine Help Enterprise 8
Remove an Assessment on the SOAP Template
Open NextGen® Enterprise EHR. In the Assessment / Plan panel, select an assessment in the grid. The Add or Update Assessment template opens. In the Today's Assessment grid, select an assessment. Select Remove. Select Yes on the confirmation message. Select Save & Close. Parent topic: Document Assessments and Plans
NextGen® Adaptive Content Engine Help Enterprise 8
Open the Assessment / Plan Details Template
Some specialties (for example, Cardiology) access the Assessment Plan Details template differently. For more information, go to NextGen Healthcare Success Community, and download the latest specialty guide of NextGen® Adaptive Content Engine for instructions if the following does not apply: Open NextGen® Enterprise EHR. Open the SOAP template. In Assessment / Plan, select A/P Details in the navigation bar. The Assessment Plan Details template opens. Assessment Plan Details Enter Assessment Plan Details You can enter comments, differential diagnoses, and details on the patient plan, provider plan, and today's orders for a selected assessment on the Assessment/Plan Details template in the A/P Details tab. Parent topic: Open the Assessments Tab Parent topic: Entering Assessments, Impressions, Differential Diagnoses, and Associated Details Parent topic: Document Assessments and Plans
NextGen® Adaptive Content Engine Help Enterprise 8
Copy Assessments from Previous Encounters
You can copy assessments from previous encounters of a patient to the current encounter instead of manually adding them. OpenNextGen® Enterprise EHR. Open theSOAPtemplate, and then expand theAssessment/Planpanel. Select Dx/AP History. The Assessment, Diagnosis Copy Forward window opens. Note: By default, the All Assessments option is selected and records are displayed for the default duration configured in the Copy Previous Visit Information section of the Practice Configuration template. To copy assessments from a specific encounter, select Encounter Assessments. To filter the records in the grid, enter the search criteria inFilter by, and then selectSearch. Note: If the records are displayed from any sensitive encounter, an asterisk (*) appears on the record in theSensitivecolumn to help you decide whether to copy such records and update the current encounter as sensitive. To select an assessment, do one of the following: From the All Assessments grid, select the record, and then sel
NextGen® Adaptive Content Engine Help Enterprise 8
Enter Assessment Plan Details
Open NextGen® Enterprise EHR. On the Assessment Plan Details template, select the A/P Details tab. To add or change a diagnosis in the Today’s Assessments grid, select Add or Edit to open the Add or Update Assessment template. To change the current working assessment, in the Today's Assessments grid, select the diagnosis being addressed for this encounter. The selected diagnosis appears in the Selected Dx field. It becomes the new working assessment that carries forward to the other templates that share the assessment. Enter details manually or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections. To enter follow-up appointment and disposition information, select Follow Up. To document counseling educational details and factors, select the Counseling Details link. To enter post-operative details, select the Postoperative Quality Reporting link. For more information on the associated quality measure, selec
NextGen® Adaptive Content Engine Help Enterprise 8
Document Follow-up Details
You can enter follow-up appointment and disposition details on the Follow-up/Disposition template. Open NextGen® Enterprise EHR. Open the SOAP template. In the Assessment / Plan panel, select the Follow Up button. The Follow-up/Disposition template opens. Follow-up/Disposition template The Follow-up/Disposition template is part of a group of templates that use the last assessment or diagnosis selected on any of the templates in the group as the working assessment. The application defaults to the current working assessment. If required, you can select another assessment, which becomes the new working assessment that carries forward to the other templates in the group. Do one of the following: Select the diagnosis in the grid. In the Follow-up section, select follow up along with other details and the suggested time for the follow-up visit. To select a new diagnosis or modify an existing assessment for the current patient, select Add/Edit Assessment. With the correct description selected
