Document a Patient's Respiration and Pulse Oximetry, Peak Flow, and Pain Level

NextGen® Adaptive Content Engine Help Enterprise 8

Vital Signs

You can add, edit or remove vital signs for a patient using the Vital Signs panel. In the Vital Signs panel you can view vital signs documented during this encounter. You can edit ot remove previously entered vital signs and enter new vital signs. The Vital Signs panel is also available on other office visit templates. The Historical information entered this encounter link opens the Vital Signs History template filtered to display only vital signs documented with patient's encounter. Using the History link, you can review the patient’s entire vital signs history on the Vital Signs History template. Using the Graphs link, you can view vital signs in graphical format on the age-appropriate VS Charts template. Vital Signs The vital signs templates are based on age. The age-appropriate template opens depending on whether the patient is less than two years old, equal to or greater than two years old, or an adult. The adult age is configured in the Pediatric Age section of the Practice Confi

NextGen® Adaptive Content Engine Help Enterprise 8

Document a Patient's Pain Level

You can document the pain level of a patient. You can document the neck, waist, and hip circumferences, audiometry exam, and vision screening findings, and orthostatic vital signs using the links on the Vital Signs template. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. On Top Toolbar, select Templates . The Select Template window opens. Open the Intake template. Expand the Vital Signs panel and select Add.The age-specific vital signs template opens. In the Pain level section, select the pain level from the list.The default method Numeric Pain Intensity Scale appears in the Method field. However, you can change the method. The pain level and method appear on the Screening Summary and Health Promotion Plan templates. To document a plan of care, select the Pain Plan link.The Health Promotion Plan template opens, where you can document the pain assessment and plan of care in the Pain Management panel. Select OK. To document the Health Assessment Questi

NextGen® Adaptive Content Engine Help Enterprise 8

Document Pain Assessment and Plan of Care

You can document the pain assessment details and follow-up plan of care. Open NextGen® Enterprise EHR. Open the Intake template. Expand the Vital Signs panel, and then select the Health Promotion Plan link. The Health Promotion Plan template opens. Expand the Pain Management panel. Note: The Pain level and Method fields display the details entered on the Vital Signs template. You cannot update the pain level and method in the Pain Management panel. Pain Management - Health Promotion Plan To manage exceptions and view measure details on the Exceptions/Measures template, select Exceptions. If details are not entered in the Pain level section on the Vital Signs template, select the following fields, and select the appropriate option in the list. Pain level Method Duration Quality To indicate to see the HPI details, select the See HPI check box. Enter the location of the pain of the patient. Select Onset, and select the date when the pain started. Enter the follow-up plan of care for a pat

NextGen® Adaptive Content Engine Help Enterprise 8

Access the Vital Signs Template

You can access the vital signs template to document the patient vital signs. Based on the configuration of the Pediatric Age section on the Practice Configuration template, different vital signs templates appear for adult patients, pediatric patients younger than two years, and pediatric patients older than two years. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. On Top Toolbar, select Templates . The Select Template window opens. Open the Intake template. Expand the Vital Signs panel and select Add. The age-specific vital signs template opens. Document the Patient's Height You can document the height of a patient in inches or in feet using the Vital Signs template. Document the Patient's Weight You can document the weight of a patient in pounds and kilograms. Document the Patient's Body Surface Area You can calculate the body surface area of a patient. Document the Patient's Temperature You can measure the body temperature of a patient. Document th

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Patient's Respiration and Pulse Oximetry

You can measure the respiratory rate and oxygen saturation level of a patient using the Vital Signs template. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. On Top Toolbar, select Templates . The Select Template window opens. Open the Intake template. Expand the Vital Signs panel and select Add. The age-specific vital signs template opens. In Respiration and Pulse Ox, enter the respiratory rate value in the Respiration field within the 0 – 99 range. Select the method of measuring the respiratory rate. Enter a value in the FIO2 field within the 20 – 100 range. Enter oxygen concentration for the patient's respiration. Enter the pulse oxygen rate during rest and ambulation of the patient within the 0 – 100 range. Note: A message appears if the value entered is not within the range. Enter the pulse oximetry resting and ambulation readings in the Pulse Ox Rest and Pulse Ox Amb fields within the 0 – 100 range. Select a source of oxygen supply. Select Pre-t

NextGen® Adaptive Content Engine Help Enterprise 8

Document Stress Echo Procedures

You can document the stress echo procedures using the Stress Echo template. Open NextGen® Enterprise EHR. On the Intake tab, select Cardiology as Specialty and Testing Only as Visit Type. Click the Stress Echo link. Note: To access the Stress Test - Card template, you can also click Stress Echo from the left navigation bar. The Stress Test - Card template opens. Select the desired options in the Pre-procedure care section. Procedure Information on Stress Test - Card template Enter the desired information in the Test/Patient data section. In the Vital Signs panel, the values for the following fields display automatically. Predicted max heart rate is calculated based on the patient’s age. Predicted max heart rate 85% is calculated based on the patient’s predicted maximum heart rate. Predicted max O2 consumption is calculated based on the patient’s age and gender. Achieved VO2 consumption is calculated based on exercise duration. Percent VO2 achieved is calculated based on Achieved O2 con

Document a Patient's Respiration and Pulse Oximetry, Peak Flow, and Pain Level

Recommendations

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Access the Vital Signs Template

Document the Patient's Respiration and Pulse Oximetry

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