Data Included in Quick Notes

NextGen® Adaptive Content Engine Help Enterprise 8

Quick Notes

Quick Notes offer a way to reduce the repetition associated with documenting information, in cases where there is a great degree of common information documented in similar clinical situations during patient visits. Quick Notes can help providers increase their productivity without compromising patient care. Quick Notes enable you to save the entire SOAP template, including all data fields, check boxes, options, and associated HPI settings under a unique name. You must later edit the information for the individual patient while using the quick note. Note: If you apply a Quick Note and subsequently apply a second Quick Note, the data associated with the second Quick Note overwrites all existing data in the template. Data Included in Quick Notes Disable the Quick Note Functionality Parent topic: Quick notes

NextGen® Adaptive Content Engine Help Enterprise 8

Save a Quick Note

The ability exists to save the current SOAP template as a Quick Notes default set. The information button at the top-left corner of the Quick Save template provides information on how to use this template to add, update, and remove a Quick Save default set. On the SOAP template, click the Quick Notes: Save button. The Quick Save template opens. Quick Save Note: The Options panel is grayed out. Enter the name of the default set in the Save As field. NextGen Healthcare recommends entering a name in the <your initial> <gender> <default name> format. For example, AK_female_Asthma HPI. Note: For gender specific defaults, use 'male' or 'female'. Select the appropriate speciality option: All Specialties - is set as the default. This option sets the Quick Save settings available across all specialties. Current Specialty Only - This option sets the Quick Save settings available only in the specialty currently open. Click Save & Close to save the default and close the Quick Save template. The Qu

NextGen® Adaptive Content Engine Help Enterprise 8

Review of SOAP Details by Provider

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, assessment plans, and provider communications. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan You can select the Record contains substance use disorder information check box on the SOAP template header to include the long or short form of disclosure for Substance Abuse and Mental Health Services Administration (SAMHSA) 42 CFR Part 2 provisions in the generated documents and reports. You can use Quick Notes to save the documented SOAP findings as a default set that can be used in future encounters. For more information on these settings, go to NextGen Healthcare Succes

NextGen® Adaptive Content Engine Help Enterprise 8

SOAP Template

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, history, and plan information. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan Although the you could enter the reason for visit and HPI on the Intake template, there are options available on the SOAP tab that are not available on the Intake tab. Parent topic: The Provider Workflow

NextGen® Adaptive Content Engine Help Enterprise 8

Reason for Visit on the SOAP Template

Open the SOAP template. Do one of the following: If the Introduction field contains text, review the content and make any necessary changes. If the Introduction field is blank, compose an introduction for the patient. The introduction appears as the first sentence of the visit note, and it can be edited for the individual patient. A typical introduction might contain the patient's age, gender, and the reason for visit. If checked, clear the Do not Launch HPI check box. To add additional details to a previously entered reason for visit, click one of the reasons for visit in the data grid. The appropriate HPI template opens. To add a new reason for visit: Select a complaint from the reasons for visit in the left pane. In the Other field select a reason from the resulting list or type a reason for visit. The associated HPI template opens. On the HPI template, enter the appropriate data. Enter any comments. Click Save & Close. The History of Present Illness column in the Reason for Visit p

NextGen® Adaptive Content Engine Help Enterprise 8

Open the Assessment / Plan Details Template

Some specialties (for example, Cardiology) access the Assessment Plan Details template differently. For more information, go to NextGen Healthcare Success Community, and download the latest specialty guide of NextGen® Adaptive Content Engine for instructions if the following does not apply: Open NextGen® Enterprise EHR. Open the SOAP template. In Assessment / Plan, select A/P Details in the navigation bar. The Assessment Plan Details template opens. Assessment Plan Details Enter Assessment Plan Details You can enter comments, differential diagnoses, and details on the patient plan, provider plan, and today's orders for a selected assessment on the Assessment/Plan Details template in the A/P Details tab. Parent topic: Open the Assessments Tab Parent topic: Entering Assessments, Impressions, Differential Diagnoses, and Associated Details Parent topic: Document Assessments and Plans

Data Included in Quick Notes

Recommendations

Quick Notes

Save a Quick Note

Review of SOAP Details by Provider

SOAP Template

Reason for Visit on the SOAP Template

Open the Assessment / Plan Details Template

Quick Notes

Save a Quick Note

Review of SOAP Details by Provider

SOAP Template

Reason for Visit on the SOAP Template

Open the Assessment / Plan Details Template