Document an Exam with the Quick Exam Defaults

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Exam Findings for Strength

The Strength panel is where strength findings are documented. The body region of the exam template determines the links that appear in the Strength panel that enable you to document strength findings for additional locations and motor tests. Strength On the General Exam PT - PE template, click a link in Strength panel to open a detailed strength physical exam template. Click Save & Close when you have finished documenting on the template. In the top section, document normal strength for the region by selecting one of the available options for Lower extremity strength normal and Upper extremity strength normal. To document that the strength is normal except for something: Select the except for checkbox. Click the corresponding field and select from the multi-select picklist. If applicable, select the top blank line from the picklist to type a value that is not in the picklist. After making selections, click Close to exit the picklist. Note: Panels on region specific physical exam templa

NextGen® Adaptive Content Engine Help Enterprise 8

Documenting a Physical Exam

Documenting a physical exam for Physical Therapy involves using exam templates that focus in detail on a specific body part, such as an upper extremity (hand) or a region (lumbar region of the spine). Physical exam templates enable you to document bilateral physical findings. For a general exam, you can use the one-page General Exam PT - PE template. Use the Physical Therapy specialty one-page General Exam PT - PE template to document a body part or region that does not have a detailed template. Use the Quick Save template defaults to document exam finding and to make changes to populated findings. The fields that appear on each panel depend on which physical exam template you have open and the region of the body you are documenting. Ensure that you complete all required fields in the physical exam templates. Document an Exam with the Quick Exam Defaults Document Observations Enter Inspection/Palpation Record a Range of Motion Findings Enter Exam Findings for Strength Record Neurovascu

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

Document a Physical Exam

The Physical Exam panel includes a list of exam categories in the left pane. The categories in the left pane are customizable by specialty or by provider on the Framework Content system template. For more information on the Framework Content system template, go to NextGen Healthcare Success Community, and download the latest Framework Content System Template forNextGen®Adaptive Content Engine. When you click the Physical Exam History button, the Historical Information window opens. You can copy the previous physical exam records to the current encounter by using the Copy Physical Exam & Close button. Click the One Page Exam link from the left pane. The applicable exam template opens. Note: The resulting window is dependent on the specialty selected. Enter any pertinent exam details. Click Quick Save to save the documented findings as the default set for the next subsequent encounters. Click Save & Close. You can also document the other findings by selecting the applicable physical exam

NextGen® Adaptive Content Engine Help Enterprise 8

Document a Multi System Orthopedic Exam

Open the SOAP template. In the Physical Exam panel, click One Page Exam in the left pane. The General Exam - PE template opens. In Location, click the region of injury from the Ort Regions list. In Quick exams, select the appropriate check boxes and click the corresponding field to display the Td Dbp Filter list. Select Normal from the Td Dbp Filter list. The respective fields in the General Exam - PE template are filled with the normal values. Select the diagnosis codes in the Dx1 or Dx2 fields. Click the corresponding Status field to select the status of each diagnosis. Click OK. View the Last Physical Exam You can view the last physical exam findings for Orthopedic patients from the General Exam - PE template. Parent topic: Orthopedic Physical Exam Templates

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

Document an Exam with the Quick Exam Defaults

Recommendations

Enter Exam Findings for Strength

Documenting a Physical Exam

Document Physical Exam Findings

Document a Physical Exam

Document a Multi System Orthopedic Exam

Document Multi System Exam on SOAP

Enter Exam Findings for Strength

Documenting a Physical Exam

Document Physical Exam Findings

Document a Physical Exam

Document a Multi System Orthopedic Exam

Document Multi System Exam on SOAP