Document an Exclusion Reason not Related to Quality Reporting
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.
Select the
Non-Codified Exclusions
link.
The
Exclusions
window opens.
To indicate the reason type, select one of the following:
Medical reason
Patient reason
System reason
A list of associated reasons appears.
Select a reason, and then select
OK
.
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NextGen® Adaptive Content Engine Help Enterprise 8
Reasons for not Documenting Patient's Vital Signs
You can document the reasons for not documenting the vital signs of a patient. The following options available on the age-specific vital signs template to document the reasons for not documenting the vital signs for a pediatric patient. The Unobtainable option enables you to make the appropriate selections in the list if you cannot document the vital signs. The corresponding fields in the vital signs panel become unavailable. The Patient Refused option enables you to make the appropriate selections from the Refused list if the patient restricted the measurement of certain vital signs. Document an Exclusion Reason not Related to Quality Reporting You can document an exclusion reason that is not related to Quality Reporting on the Exclusions window when documenting vital signs. Parent topic: Patient Vital Signs Parent topic: Access the Vital Signs Template Parent topic: Add Vital Signs of Pediatric Patients
NextGen® Adaptive Content Engine Help Enterprise 8
Document Historical Vital Signs
You can document the historical vital signs for a patient. 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 recorded historical vital signs. In Weight measurement, document the patient's weight in the lb and kg fields within the 4.409 – 1543.3 lb or 2.00 – 699.99 kg range. Note: An alert message appears if the value entered is not within the range. In Blood Pressure and pulse, document the patient's Systolic and Diastolic readings within the 0 – 399 range, and then document the patient's pulse rate within the 10 – 499 range. Note: An alert message appears if the value entered is not within the range. Select Measured date, and select the corresponding historical date. To enter the time details, select Time, and select the corresponding historical ti
NextGen® Adaptive Content Engine Help Enterprise 8
Document the Patient's Weight
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. Enter the weight of the patient in the lb field or kg field within the 4.409 – 1543.2 lb or 2.00 – 699.99 kg range, respectively. Based on the value entered in the lb or kg field, the other field is filled automatically. If the value entered is not within the range, a message appears to indicate that the value entered is out of range. To indicate if the patient was wearing shoes when the body weight is measured, select a Context option. Save and close the template. When you enter the height and weight on the Adult Vital Signs template, NextGen® Enterprise EHR automatically calculates the Body Mass Index (BMI). If the BMI is not within the normal range, a message appears based on the configuration on the Vital Signs Configu
NextGen® Adaptive Content Engine Help Enterprise 8
Document the Patient's Height
You can document the height of a patient in inches or in feet 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. Select Add. The age-specific vital signs template opens. In Height/length measurements, do one of the following: To enter the current day's data, fill the ft, in, or cm fields within the 1 – 9.99 ft, 12 – 119.88 in, or 30.48 – 304.49 cm range, respectively. To enter previously documented data, select the Carried forward option. If you enter the height in either the ft, cm, or in field, the NextGen® Enterprise EHR fills values in the other fields automatically. Note: A message appears if the value entered is not within the range. Adult Vital Sign Indicate the position of the patient when the height is measured. To enter the date when the patient's height is measured, select a date in Last M
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 a Patient's Height, Weight, BSA, Temperature, Blood Pressure and Pulse
You can document a patient's height, weight, BSA, temperature, blood pressure and pulse using the Vital Signs panel. The Vital Signs panel is where you can view vital signs documented during this encounter. Previously entered vital signs can be edited or removed, and new vital signs can be entered. The Vital Signs panel is also found on other office visit templates. Open NextGen® Enterprise EHR. Select the Care Guidelines link on any of the main template.The Care Guidelines Paged View template opens. In the Care Guidelines panel, select the Grid View link.The Care Guidelines grid view template opens. In the Vital Signs panel, select Add. Vital Signs The Adult Vital Signs [New Record] template opens. The Measured Date, Time and the Measured by fields fill in automatically. Note: You can change the date but you cannot modify the user name. If you cannot document the vital signs, select the Unobtainable check box and make the appropriate selections from the list to document what was not a
.
The Select Template window opens.