Document a Physical Exam

NextGen® Adaptive Content Engine Help Enterprise 8

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

The Pre-procedure Evaluation panel enables you to view and add patient's physical exam findings and generate the ASC Chart Note document after review and signoff. You can use the My Phrases link at the top-right of the Comments field to add comments. For more information on managing and using the My Phrases functionality, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide forNextGen®Adaptive Content Engine. After entering the appropriate data in the Physical Exam, select the No or Yes option for the Patient remains an appropriate candidate to undergo the planned procedure check box to indicate whether or not the physician can consider performing any further planned procedures on the patient. The following options are available at the bottom of the Pre-Procedure Evaluation panel: Normal history and physical - Indicates that the pre-procedure evaluation findings are normal. History and physical reviewed, no changes - Indicates that the existing

NextGen® Adaptive Content Engine Help Enterprise 8

Document Physical Exams

As part of the provider workflow, you can document and manage physical exams performed for a patient. OpenNextGen® Enterprise EHR. Open theSOAPtemplate, and then expand thePhysical Exampanel. To document findings for multiple physical exams on a single template, select One Page Exam from the left navigation bar. Note: You can also select Load to quickly load any saved physical exam findings, or Save to save the documented physical exam findings to use them on other encounters. To document findings for a single physical exam, select an appropriate link from the left navigation bar. To document findings for a physical exam that does not appear in the left navigation bar, select Additional. To copy physical exam findings from a previous encounter to the current encounter, select Physical Exam History.If you have copied and edited information from a previous encounter, a label appears in the Physical Exam panel and applicable documents indicating that information is copied and edited. Note

NextGen® Adaptive Content Engine Help Enterprise 8

Copy Physical Exam Findings from Previous Encounters

You can copy physical exam findings from previous encounters of a patient to the current encounter instead of manually adding them. OpenNextGen® Enterprise EHR. Open theSOAPtemplate, and then expand thePhysical Exampanel. Select Physical Exam History. The Historical Information window opens. Note: The records are displayed for the default duration configured in the Copy Previous Visit Information section of the Practice Configuration template. For more information, go to NextGen Healthcare Success Community, and download the latest Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. To filter the records in the grid, enter the search criteria inFilter by, and then selectSearch. Note: If the records are displayed from any sensitive encounter, an asterisk (*) appears on the record in theSensitivecolumn to help you decide whether to copy such records and update the current encounter as sensitive. Select the record to copy, and then select Copy Physical Exam & Cl

NextGen® Adaptive Content Engine Help Enterprise 8

Document Multi System Exam on SOAP

You can document the complete physical examination details of a patient on the SOAP template. The One Page Exam link in the left pane on the Physical Exam panel enables you to open the One Page - Physical Exam template. Note: Based on how the One Page Exam template is configured in the Physical Exam section on the Framework Content system template, and whether the Enable Gender Neutral PE check box is enabled in the SOGI/Transgender section on the Practice Configuration template, a gender-specific or a gender-neutral One Page - Physical Exam template opens. For more information, go to NextGen Healthcare Success Community, and download the latest Framework Content System Template forNextGen®Adaptive Content Engine and Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. Open NextGen® Enterprise EHR. Open the SOAP template. In Physical Exam, select the One Page Exam link in the left pane. The One Page - Physical Exam template opens. One Page - Physical Exam Ente

NextGen® Adaptive Content Engine Help Enterprise 8

Document Physical Exam Findings

You can document the complete physical examination details of a patient on the SOAP template. The One Page Exam link opens a gender-specific or a gender-neutral, one-page physical exam template. Based on the configuration in the Physical Exam panel of the Framework Content system template and the selection of the Enable Gender Neutral PE check box on the Practice Configuration template, the gender-specific or a gender-neutral, one-page physical exam template opens. For more information, go to NextGen Healthcare Success Community, and download the latest Framework Content System Template forNextGen®Adaptive Content Engine and Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. Open NextGen® Enterprise EHR. On the SOAP template, expand the Physical Exam panel. Select One Page Exam. The One Page - Physical Exam template opens. One Page - Physical Exam Document your findings on the template. Note: To save the documented value as the default set, you can select th

NextGen® Adaptive Content Engine Help Enterprise 8

Patient Recalls Panel on the ASC - Physician Procedure Template

The Patient Recalls panel enables you to document patient recalls to the NextGen® Enterprise PM. For information on Patient Recalls panel documentation, see Patient Recalls Panel on the Home Page - Ambulatory Surgery Template. Patient Recalls The Patient Recalls panel includes the Quality button on the panel header. When you click the Quality button, the Information Display opens displaying the clinical quality measure ASC - 9 and ASC - 10 on Endoscopy/Polyp Surveillance. The Exclusions link opens the CQM Results template to document medical exclusions. You need to select the measure in the grid at the bottom of the CQM Results template and click the Exclusion field to select the appropriate medical exclusion. If you want to save the documented values as the default set to upload in a template for a new patient, click the quick save button and enter a default set name for the template. To upload the default set values into the template, click the quick load button and select the defaul

Document a Physical Exam

Recommendations

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

Document Physical Exams

Copy Physical Exam Findings from Previous Encounters

Document Multi System Exam on SOAP

Document Physical Exam Findings

Patient Recalls Panel on the ASC - Physician Procedure Template

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

Document Physical Exams

Copy Physical Exam Findings from Previous Encounters

Document Multi System Exam on SOAP

Document Physical Exam Findings

Patient Recalls Panel on the ASC - Physician Procedure Template