Care Plan Components

Field	Description
Type	The type of care plan
Status	The status of the care plan
Intent	The intent of the care plan

Panel	Description
Add/Edit Health Concerns	Consolidates categorized health concerns from several sources within the application Health concern categories include but are not limited to allergy, vital signs, social history, smoking and tobacco use.
Patient Care Team Members	Displays information about a patient's care team and enables providers to update the care team by adding modifying members
Functional and Cognitive Assessment Status	Enables providers to record functional and cognitive assessments for patients
Goals, Interventions, and Outcomes	Enables providers to define goals, identify interventions, and track outcomes for identified patient health concerns
Care Plan History	Displays a history of a patient's care plan in order by the encounter date History includes identified concerns, goals, interventions and outcomes.
At A Glance	summarizes the care plan related activities for the current encounter.

NextGen® Adaptive Content Engine Help Enterprise 8

Create a Care Plan

Before you begin Make sure that the existing care plans for the patient are in Completed status. From the navigation, click Care Plan. The Care Plan template appears. Care Plan template Click Create a New Care Plan. All the panels gets activated. Activated panels on the Care Plan template Select a status, and an intent. The default values are Active, and Plan respectively. Add a health concern. Add goals to address health concern. Add interventions to achieve the goals. Record functional and cognitive assessments. Click Save and Close. Note: To edit a completed care plan, you must update the status of the current plan to Entered-in-Error, which removes the current care plan's data and redirects you to the previous care plan. Care Plan Statuses You can view or update the status of a care plan from the Status field of the Care Plan template. Parent topic: Patient Care Plans

NextGen® Adaptive Content Engine Help Enterprise 8

Patient Care Plans

You can create a care plan to address patients' health concerns and monitor their progress toward resolving specific concerns. On the Care Plan template, you can do the following: Define and maintain a care plan for a patient that addresses health concerns, goals, interventions, and outcomes Record the functional and cognitive status of the patient Define, track, and review interventions by multiple providers and agencies Track the overall progress of the patient toward achieving defined goals The Care Plan template also enables you to meet the 2015 edition certification criterion, which requires a recording, changing, accessing, creating, and receiving care plan information. This information is in accordance with the structured format of the Care Plan document template in the HL7 Implementation Guide for CDR® Release 2: Consolidated CDA Templates for Clinical Notes. You can also create a Care Plan document from the Care Plan template and save the document as part of the encounter hist

NextGen® Adaptive Content Engine Help Enterprise 8

Care Plan

You can use the Care Plan templates to address patients' health concerns and monitor their progress toward resolving specific concerns. Patient Care Plans You can create a care plan to address patients' health concerns and monitor their progress toward resolving specific concerns. Manage Health Concerns Manage Goals, Interventions, and Outcomes Patient Care Team Members Document Functional and Cognitive Assessments You can document a patient's functional and cognitive assessments in the Functional and Cognitive Assessment Status panel. Review a Patient's Care Plan History View At A Glance Panel Related concepts Patient Care Plans Manage Health Concerns Manage Goals, Interventions, and Outcomes Patient Care Team Members Review a Patient's Care Plan History Related tasks Document Functional and Cognitive Assessments View At A Glance Panel

NextGen® Adaptive Content Engine Help Enterprise 8

Plan/Intervention Tab

You can define various team members who are going to provide healthcare services to a patient and maintain patient circumstances using the Plan/Intervention tab. The Plan/Intervention tab consists of the following panels: Panel Description Care Coordination Team This panel enables you to define the various team members who are going to provide healthcare services to a patient. When defining team member, you identify the individual provider and the agency with which the provider is associated. Barriers to Care This panel enables you to record and track patient circumstances that may negatively impact the patient’s ability to comply with the requirements of the nursing care plan. History This panel lists all the nursing care plans that have been created for a patient. These plans can be created on the History panel. Interventions This panel lists the current interventions that have been defined for a patient along with the relevant data necessary to define the intervention. Progress This

NextGen® Adaptive Content Engine Help Enterprise 8

Add a Patient Goal to Address a Health Concern

You can add multiple goals to a single health concern. To add multiple goals, repeat this procedure for each goal. From the navigation bar, click Care Plan. The Care Plan template appears. Expand the Goals, Interventions and Outcomes panel. The Select a Health concern to document section appears with all previously added health concerns. Goals, Interventions and Outcomes panel Select a health concern from the list. The information about the selected health concern goal fields appears on the right. Goal details on the Goals, Interventions and Outcomes panel In the Goal field, type a goal description to address the health concern, or use Common Phrases. Indicate if the goal is a patient goal or a provider goal. Verify that the life cycle status of the goal is set to Active. You can also change the status. For Goal achieved, do one or more of the following: Select Yes, No, Goal not attainable, or No progress toward goal. Click the field below and then select an option from the list that a

NextGen® Adaptive Content Engine Help Enterprise 8

Manage Health Concerns

The first step in managing patient care is to identify and add the patient health concerns that you, as the provider, would like to address using a care plan. Prior to using the template, you must have entered health care concerns for the patient, either during the current encounter or during prior encounters. Allergies, smoking status, alcohol or drug use, family history, vital signs, and so on would appear as health concern categories on the Care Plan template. Add a Health Concern You can add a health concern to a patient's care plan from Add/Edit Health Concerns panel of the Care Plan template. Add a Health Concern Using the Other Category Update a Health Concern Remove a Health Concern Parent topic: Care Plan

Care Plan Components

Recommendations

Create a Care Plan

Patient Care Plans

Care Plan

Plan/Intervention Tab

Add a Patient Goal to Address a Health Concern

Manage Health Concerns

Create a Care Plan

Patient Care Plans

Care Plan

Plan/Intervention Tab

Add a Patient Goal to Address a Health Concern

Manage Health Concerns