Document Assessments and Plans

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Assessment Plan Details

Open NextGen® Enterprise EHR. On the Assessment Plan Details template, select the A/P Details tab. To add or change a diagnosis in the Today’s Assessments grid, select Add or Edit to open the Add or Update Assessment template. To change the current working assessment, in the Today's Assessments grid, select the diagnosis being addressed for this encounter. The selected diagnosis appears in the Selected Dx field. It becomes the new working assessment that carries forward to the other templates that share the assessment. Enter details manually or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections. To enter follow-up appointment and disposition information, select Follow Up. To document counseling educational details and factors, select the Counseling Details link. To enter post-operative details, select the Postoperative Quality Reporting link. For more information on the associated quality measure, selec

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

Add Birth Control Information

Ensure that Title X fields are configured in the Practice Configuration template. OpenNextGen® Enterprise EHR. Select a patient, create an encounter and then select the Specialty as Family Practice and Visit Type as Office Visit. On the SOAP template, expand the Assessment / Plan panel. To include the confidential details in the master documents, select the Include all Title X contraception information in the document with patient permission check box. To add a reason for No Birth Control Information (BCM), click Reason for No Birth Control Method at End of Visit. To add a contraception method, click Contraception Provision Method. To add or update BCM, click Birth Control Information at End of Visit. Note: You can add up to two birth control methods. Save the changes. Parent topic: Configure Title X in Assessment / Plan

NextGen® Adaptive Content Engine Help Enterprise 8

Copy Assessments from Previous Encounters

You can copy assessments from previous encounters of a patient to the current encounter instead of manually adding them. OpenNextGen® Enterprise EHR. Open theSOAPtemplate, and then expand theAssessment/Planpanel. Select Dx/AP History. The Assessment, Diagnosis Copy Forward window opens. Note: By default, the All Assessments option is selected and records are displayed for the default duration configured in the Copy Previous Visit Information section of the Practice Configuration template. To copy assessments from a specific encounter, select Encounter Assessments. 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. To select an assessment, do one of the following: From the All Assessments grid, select the record, and then sel

NextGen® Adaptive Content Engine Help Enterprise 8

Configure Title X in Assessment / Plan

You can enable Title X fields on the Practice Configuration template to display the Birth Control Information field. OpenNextGen® Enterprise EHR. From theFilemenu, selectSystem \ Practice Template. TheSelect Templatewindow opens. From theShowsection, selectAll. Click the Practice tab. A list of practice level templates appears. Select Practice Configuration, and then click OK. The Practice Configuration template opens. From the Title X Fields section, select the Enable Title X fields check box. Additional fields appear on the Title X 2.0 content for the practices that need to adhere to the Title X FPAR 2.0 standards. Add Birth Control Information You can document Birth Control Information (BCM) for a female adult patient if Title X fields are configured. Parent topic: SOAP Template Parent topic: Document Assessments and Plans Related tasks Add Birth Control Information

NextGen® Adaptive Content Engine Help Enterprise 8

Document Follow-up Details

You can enter follow-up appointment and disposition details on the Follow-up/Disposition template. Open NextGen® Enterprise EHR. Open the SOAP template. In the Assessment / Plan panel, select the Follow Up button. The Follow-up/Disposition template opens. Follow-up/Disposition template The Follow-up/Disposition template is part of a group of templates that use the last assessment or diagnosis selected on any of the templates in the group as the working assessment. The application defaults to the current working assessment. If required, you can select another assessment, which becomes the new working assessment that carries forward to the other templates in the group. Do one of the following: Select the diagnosis in the grid. In the Follow-up section, select follow up along with other details and the suggested time for the follow-up visit. To select a new diagnosis or modify an existing assessment for the current patient, select Add/Edit Assessment. With the correct description selected

Document Assessments and Plans

Recommendations

Enter Assessment Plan Details

Document Physical Exams

Add Birth Control Information

Copy Assessments from Previous Encounters

Configure Title X in Assessment / Plan

Document Follow-up Details

Document Assessments and Plans

Enter Assessment Plan Details

Document Physical Exams

Add Birth Control Information

Copy Assessments from Previous Encounters

Configure Title X in Assessment / Plan

Document Follow-up Details