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Comp Assessment Tab
You can document a patient's comprehensive assessment using the
Comp Assessment
tab.
Comp Assessment Panels
Comp Assessment General Panel
Document Recent ER Visits (in last 12 months) Panel
Record Recent Patient Hospitalizations
Comp Assessment Problem List Panel
Active and Managed Problems Panel for the Comp Assessment Tab
Nursing Care Plan History Panel for the Comp Assessment Tab
Viewing Patient Medications
You can view the patient's medications in the Medications panel on the Intake template.
Medication Reconciliation for a Patient
Medication reconciliation is a review of patient adherence to prescribed medications.
Patient's Social History
You can document a patient's social history.
Review of Systems Panel
Patient/Caregiver Concerns Panel
NextGen® Adaptive Content Engine Help Enterprise 8
Document a Medication
You can add medications details for the treatment of a patient. Open NextGen® Enterprise EHR. On the Intake template, in the Medications panel, select Add /Update. The Medication Module window opens. Select Prescribe New. The Medication Search window opens. Search for a medicine from the list, and then select Select. Enter the start and stop date of the medication that the patient needs to take. Enter the quantity of the medication. To mention when and how the patient can take the medication, select Edit Sig:. Enter the number of refills allowed on the prescription of the patient. Enter the problem of the patient. If the medications are already prescribed, select the Prescribed elsewhere check box. Select Accept. Close the Medication module. In the Medications panel, to enter additional information about the medications, select the Comment link. Note: You must not use the medication comment template to list the patient's current medications. You can use the template as a temporary loca
NextGen® Adaptive Content Engine Help Enterprise 8
Medications
You can document and manage the medication history and current medications of a patient. You can use the Medications panel to view the patient's current medications and medication history, enter additional prescriptions for the patient, and reconcile the medications listed with the actual active medications for the patient. You can use the No medications this encounter check box if there are no active medications for the patient. Medications Panel You can reconcile the medications for the patient using the Medications reconciled check box, and indicate that you have received the summary of care for the patient using the Summary of care received check box. You can select the Reconcile button to use the following: Medication Review to review the patient medication on the Medication Review template Electronic Reconciliation to electronically reconcile the medications on the Clinical Reconciliation template The documented medication records appear in rows. If narcotic medications are docum
NextGen® Adaptive Content Engine Help Enterprise 8
Medications Panel on the ASC - Intake Template
The patient's medication details documented on the ASC -Scheduling Questions template or ASC - Pre admission template appear in the Medications panel of the ASC - Intake template. For information on the Medications module documentation, see Medications Module. The intake staff reviews and makes the necessary changes to the patient's medication details as appropriate on the ASC - Intake template. You can view the patient's active medications and the medications prescribed, modfied, and renewed during the selected encounter in the Medications panel. You can enter additional prescriptions for the patient, and reconcile the medications listed with what medications the patient is actually consuming and how the patient is consuming them. The No medications this encounter check box selection is encounter-based. If you select the No medications this encounter check box for a previous encounter and prescribe medication in a current encounter by selecting the Prescribed Elsewhere check box, then
NextGen® Adaptive Content Engine Help Enterprise 8
Documentation Tab
You use the Documentation tab to document interactions with a patient that fall outside of a patient visit. For example, interactions with other providers, telephone calls and interactions with other care team members. The Documentation tab consist of these panels: Panels Description Provider Interactions Use this panel to record interactions with other providers. Telephone Interactions Enter patient’s interactions over the phone on this panel. Face-to-Face Interactions Enter patient’s face-to-face interactions on this panel. Care Coordination Interactions Enter patient’s care coordination-related interactions on this panel. Document Use this panel to add or update the visit diagnosis codes, document the type of visit, submit the encounter visit code, and generate the visit note. The Document panel also contains links to generate several care management documents. Document Provider Interactions Document Telephone Interactions Record Face-to-Face Interactions Record Care Coordination In
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
Comp Assessment Panels
The Comp (Comprehensive) Assessment template consists of the following panels: Panel Description General Panel The General panel displays the information documented in the Care Transition template. Recent ER Visits Panel Any recent emergency room visits by the patient are recorded on this panel. Recent Hospitalizations Panel If the patient had experienced any recent hospitalizations, then you would enter that information on this panel. Problem List Panel The Problem List panel displays a list of the patient's chronic and secondary problems as documented in the Problem List after Discharge panel on the Care Transition template. Active and Manage Problems The Active and Managed Problems panel is where active and managed problems are entered and monitored. Nursing Care Plan History The Nursing Care Plan History panel lists all the nursing care plans that have been created for a patient. Medications Panel This panel is documented in a variety of NextGen Adaptive Content Engine documents, i
