NextGen Knowledge Center

Add Fracture Care Rapid Note

  1. Click the SOAP tab and click the Rapid Note sub-navigational link.
    The Fracture Care Rapid Note template appears.
    Fracture Care Rapid Note

  2. In the Indication/Type of Treatment panel, the grids will be filled from the options selected and documented in the Fracture/Casting /Strapping template.
  3. If a patient has a new treatment that needs to be added, do the following:
    1. Select the required options for the Episode of Care and the Type of Treatment fields.
    2. Select the required options for the following fields from the corresponding picklists:
      • Indication
      • Type of treatment
      • Side
      • Region
      • Initial Treatment Date
      • Click Add.
      The information is displayed in the grid.
    3. Select the required options for the following fields:
      • Status
      • WB Status
      • Pain meds
      • Using assistive device
      • Select the Pain level and Frequency of pain from the corresponding picklists.
  4. In the Associated symptoms/pertinent negatives section,
    1. Select the required options for the Activity Level and Work status from the corresponding picklists.
    2. Select the required check box for the patient if there are No associated symptoms, No pertinent negatives, and if All others are negative.
    3. Click the required buttons for the present symptoms.
    4. Select the required options for the Other associate symptoms and Other pertinent negatives if there are any from the corresponding picklists.

      If you click the ADLs link, it displays the PT Patient Report template to select appropriate patient data.

      If you click the Functional Limitations link, it displays the Functional Limitations template to select the required patient data.

  5. In the Fracture treatment and management section,
    1. Select the required check boxes.
    2. Select a date from the Patient removed cast calendar.
    3. Click Other to select a treatment.
  6. In the Complications section, click the required options.
  7. In the Procedures section, select a procedure link.
  8. In the Physical Exam panel, record the exam findings.
  9. In the Assessment/Plan panel, if any assessment is previously selected, it will automatically populate the details of the assessment.
  10. Click the Add Common Assessment link to add or remove a new common assessment.
  11. In Today's Assessments, select an assessment. You can add, edit, or remove the assessment.
  12. Select the required options for each section.
    You can use the Assessment/Plan Details, Diagnostics, and CC: Providers links in the My Plan section to add information about the assessments, diagnostics, and providers respectively.
  13. Click Save & Add New.
  14. Click Save & Close.