Add Assessments or Plans
- Open NextGen® Enterprise EHR.
- Open the SOAP template.
- Click the Assessment/Plan panel.
- From the left pane, click an assessment category link.
The diagnosis search window displays a list of diagnoses for the category selected.
- Select an appropriate diagnosis and then click Select.
The diagnosis has been added to and displayed in the grid with the letter “D” and lines for A and P.
- Click the A row in the grid for a diagnosis.
The Assessment And Plan template opens.Note: Certain diagnosis requires you to choose a category before documenting the details. This allows the appropriate assessments that match the ICD-10 code to display.
- To enter an assessment or plan, do one of the following:
- Click Type an assessment below the Status field.
- Click Type a Plan below the Plan Type field.
Note: To use phrases, click the My Phrases link and then select an option from the list. For more information, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide for NextGen® Adaptive Content Engine. - Click the desired items listed in the Status column on the left.
The Assessment field on the bottom left of the template displays the details of the selected assessment.
- Document a plan by clicking on an item listed in the Plan Type column.
The Plan column are updated to display a list of plan items for the selected plan type.
Click the Exclusions link if you want to document exclusions for medical, patient, and system for patients whom a referral to Cardiac Rehabilitation is not given for the Cardiology specialty.
- Click the desired items listed in the Plan column on the right.
The Plan field on the bottom right of the template displays the plan details.
After selecting a plan detail item, the Plan column changes to display a Choice list.
- Click on one or more items in the Choice column as appropriate.
Then plan and choices selected are displayed in the large Plan text field on the bottom right of the template.
- Document the plan by selecting the next Plan Type. Follow the same process if necessary.
- Click Accept.
Note: During an upgrade, when updates are made in the Card_planToOrderItems table in File Maintenance, make sure to change the KBM_ind column to 'N' for every row you modify in the Card_planToOrderItems table. The items are cleared and re-populated when kbm_ind column is set to 'Y'. Your previously saved custom data is retained in the Assessment And Plan template after an upgrade change the Kbm_ind column to 'N'.