Document a Specific Complaint

NextGen® Adaptive Content Engine Help Enterprise 8

Document a Routine Visit

After the intake staff completes their work with the patient, you can document the patient encounter. On Dermatology Home Page template, review the patient information entered by the intake staff. On the Histories template, review the patient information and make the desired modifications. On the SOAP template, view the details of reason for entered by the intake staff in the Reason for Visit panel. You can enter additional reasons for visit. In the Review of Systems panel, to document patient's signs and symptoms, do one of the following: Click the ROS defaults field, and then select an appropriate default ROS from the list. Click DERM - ROS and do one of the following in the Dermatology-ROS template. To select negative or positive for symptoms in a system, select either Neg or Pos options. To mark negative for all symptoms in a specific system, select All neg in the respective system. To document the findings in detail for a specific system, click the respective system link, and then

NextGen® Adaptive Content Engine Help Enterprise 8

Document Review of Systems Details

Open the SOAP template. In the Review of Systems panel, do one of the following: To select normal for all systems, click the ROS Defaults field, and then select default ROS from the list. To document the findings for multiple systems on a single template, click Derm ROS To document the findings for a specific system, locate the respective system on the ROS template, and then document your findings. To mark negative for all symptoms in a system, select All Neg in that system. To document the findings in detail for a specific system, click the respective system link, and then document the findings. Document the updates in the template. Click Save & Close. The option exists to save the documented information in the ROS template as the default set with a unique name, allowing you to use it again when documenting on the same template during future patient encounters. To copy the previous review of systems information to the current encounter, click ROS History. The Historical Information wi

NextGen® Adaptive Content Engine Help Enterprise 8

Complete the Derm Quick HPI Template

The Derm Quick HPI template enables you to enter the following patient information: General information about the patient's chief concern Dermatology specific information, including location of concern, skin type, cancer history and date of last exam Current and previous treatments Additional relevant details You can add up to six complaints on the HPI grid. In the Reason for Visit panel of the SOAP template, click derm quick hpi in the left pane. The Derm Quick HPI template opens. In the General panel, click the Concern field and select the patient's chief concern from the resulting list. To enter a duration for the concern, click the Duration field and use the resulting calculator. If this is a follow-up exam for treatment of the chief concern, click the Follow up check box. To select the current status of the concern, click Status. To indicate the date that the patient first noticed the concern, click Lesion noticed. If appropriate, select a Severity for the concern, either Mild, Mo

NextGen® Adaptive Content Engine Help Enterprise 8

Document Exam Findings with GET

Create a patient encounter. On the Intake template select the Specialty as Dermatology and the Visit Type as Office Visit. In the Reason for Visit panel, select a reason for visit. To open the Graphical Exam Tool template, click the GET tab. On the Graphical Exam Tool template, the Reason for Visit pane shows the first reason for visit and you can do the following in the pane: Use the right arrow to display the next reason for visit. Use the left arrow (when enabled) to display the previous reason for visit. Note: You can add all the findings for a visit on a single reason for visit, or you can add the appropriate findings for each reason for visit. The right arrow is enabled if there are additional reasons for the visit. Select the areas examined on the Areas Examined panel. Click a finding in the FINDINGS list and then click the locations on the image where that finding appears. As you add findings, a record for each finding is added to the Reason for Visit grid beneath the image. To

NextGen® Adaptive Content Engine Help Enterprise 8

Document Review of Systems

The Review of Systems panel enables you to document the findings after reviewing a list of systems. Click Derm - ROS in the left pane to access the Dermatology - ROS template. Note: To copy the previous review of systems information to the current encounter, click ROS History. The Historical Information window opens, click Copy ROS & Close to copy previous review of systems information to the current encounter on the SOAP template. On the Historical Information window you can view Encounter Date, Provider, Reason for Visit/HPI, Diagnosis and copy System and Findings, Comments and Narrative to the current encounter. You can search or filter for specific content on the Historical information window by using the picklist available for each field except Findings, Comments and Narrative. For Findings, Comments and Narrative, you must type minimum 3 characters to enable the Search button. Click ROS Default field to access the Td Dbp Filter window with default ROS questions.This list can be m

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

Document a Specific Complaint

Recommendations

Document a Routine Visit

Document Review of Systems Details

Complete the Derm Quick HPI Template

Document Exam Findings with GET

Document Review of Systems

Reason for Visit on the SOAP Template

Document a Specific Complaint

Document a Routine Visit

Document Review of Systems Details

Complete the Derm Quick HPI Template

Document Exam Findings with GET

Document Review of Systems

Reason for Visit on the SOAP Template