Add Interim History

You can add interim history information for a patient. You can document all patient medical encounters, which includes but is not limited to, hospitalizations, emergency room visits, office visits, and same day surgeries.

1. Open NextGen® Enterprise EHR.
2. To open the Interim History template, do one of the following:
   • On the Histories template, expand the Medical/Surgical/Interim panel, and then select Interim History.
   • In the History Summary panel on Intake, select Interim, and then select Add.
   The Interim History template opens.

   

3. Select an encounter type.
   Note: If an encounter type does not appear in the list, you can manually enter it.
4. Select the Problem field and select a problem from Patient Problems.
   If problems are added during previous encounters, the Patient Problems template opens. If there are no problems from previous encounters, then a search window opens.
5. To select a problem, do one of the following:
   • From the Patient Problems list, select an existing problem.
   • From the search window, search for and select a problem, and then select the Add to Problem List button.

   Note: If you manually enter the problem, the Add to Problem List button does not get enabled.
6. In the Management field, enter the therapy or procedure performed on the patient.
7. Select the current date and then the provider who performed the therapy or procedure. If a provider does not appear in the list, you can manually enter the name.
8. Enter admission details, discharge details, and outcome or detail of the therapy or the procedure.
9. Enter discharge diagnoses (up to four), additional comments, and then select Save.
10. To document another interim history record, select Clear For Add.
11. Select Close.
    The history record appears in the grid. If you have not selected a review status previously, NextGen® Enterprise EHR selects Reviewed, updated.