Document Information in the Assessment/Plan Panel

NextGen® Adaptive Content Engine Help Enterprise 8

Document Information in the Prenatal Visits Panel

The Prenatal Visits panel contains a grid with data entered from all previous prenatal visits for the current pregnancy. The comments can be viewed in two ways. Open the Prenatal Visits panel. Select the row with an asterisk in the comments column, and view the full text of the comment in the Progress note field below the grid. Select the Progress Note Summary button. The Pregnancy Note Summary template opens, Prenatal Visits Select the OB Initial Exam link. The OB Initial Physical Exam window opens. Select the Default normal check box. All physical exam items up to the Adnexa item are marked as normal except for the Uterus size item. Any item that is not normal can be manually changed. Uterine size must be manually entered. Other exam items can be entered as needed. Note: If the initial exam is completed at the initial visit, the Lock (complete)initial physical exam check box at the bottom indicating that the exam is complete can be selected. If this check box is not selected, the pro

NextGen® Adaptive Content Engine Help Enterprise 8

Components of the Prenatal Detail - Obstetrics Template

You can document the necessary information about prenatal encounters and review data from previous encounters to ensure safe and effective care for a pregnant woman and her baby on the Prenatal Detail - Obstetrics template. The following panels enable you to document the necessary information during a prenatal visit: General OB Problems Prenatal Visits Assessment/Plan Orders Diagnostic Studies The obstetric group of panels are used for orders: Initial Orders 24-28 Week Orders 32-37 Week Orders Genetic Screening and Testing Maternal Carrier Screening Fetal (Aneuploidy) Chromosomal Testing Ultrasound Orders Optional Orders You can view telephone calls and other communications outside of visits in the Communication panel. Note: You can open the OB Gestational Orders template from the OBGYN Lab Master template. The lab results opens the Order Management template or the Order module. The Risk Factors link in the OB patient header opens the OB Risk Factors template to document risk factors t

NextGen® Adaptive Content Engine Help Enterprise 8

Document Assessment/Plan in the OB Postpartum Template

Select the Postpartum tab. Select the Physical Exam panel. Select the Add/Update button in the Assessment/Plan panel. The Add or Update Assessment template opens. Add or Update Assessment Enter the applicable information in the Add or Update Assessment template. By default the ICD-10 code displays in the Assessment/Plan grid. The system assigns the ICD code to the Assessment field on the template. This code displays by default for the Visit Type of OB Postpartum and does not include Document Pregnancy Outcome which is typically done without the patient being present. Select Save & Close. To enter information in the Consent – Procedures template, select the Consent link. To generate the proc_consent document, select the Consent button. To enter information in the Procedure Scheduling link, select theProcedure Scheduling button. Select the CQM icon to display information for the CQM – Maternity Care – Post-Partum Follow-up and Care Coordination measure. In the Counseling section, select

NextGen® Adaptive Content Engine Help Enterprise 8

Using the Assessments Tab

The Assessments tab in the My Plan template set houses the Add or Update Assessment template. The grids on the Assessments tab can be filtered. For example, in the Billing Diagnosis History section, selecting the Show Chronic only check box displays only those diagnoses that are not acute. Selecting the option to Add Assessments on 1 click speeds up the documentation process by including the diagnosis description and code for Today's Assessment in the grid and Problems module without having to click Add/Update. The Medications or Immunizations links can be used at any time during the encounter to access the associated module. Open the Assessments Tab Document an Assessment You can document an assessment on the Add or Update Assessment template. Shared Working Assessment The group of templates that share the selected assessment for the patient. Change the Order of Assessments in the Grid Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the To

NextGen® Adaptive Content Engine Help Enterprise 8

Add Diagnosis from Today’s Assessment to Obstetric Problems List

The Today’s Assessment grid displays all diagnoses from a patient's current encounter. You can select a relevant obstetric (OB) problem diagnosis from today’s assessment and move it to the patient’s current OB problems list. On the Prenatal Detail template, expand the OB Problems panel and select Add/Update. The OB Problem Add template opens. In the Today’s Assessment section, select the diagnosis that you want to add to the OB problems list. Select Send to OB Problems. Select the assessment status and priority. To add an OB problem to the Problems module, select Add to Problems Module, and then the relevant SNOMED code on the resulting window. To add notes, select 'Date Stamp' Note and then enter your notes. Note: The date stamp inserts the current date and the username. Select Add/Update. Parent topic: Obstetric Problems Related tasks Access Obstetric Prenatal Detail

NextGen® Adaptive Content Engine Help Enterprise 8

Add or Update Assessment Template

The Assessments link in the My Plan template enables you to open the Add or Update Assessment template. The Add or Update Assessment template enables you to add and update assessments. Add or Update Assessment Grids in Add or Update Assessment Template Open the Assessments Tab Patient's Treatment Plan The treatment plan for the patient can be documented on the My Plan or My Custom Plan template. Patient's Lab Orders You can place lab orders from the Labs tab using the Lab Master template or the Orders console. The Process and Submit Lab/Radiology Orders template shares information with the Lab Master template and the Orders console. Place an Order for Diagnostic Studies You can place a diagnostic study order with Bypass Order Module Processing enabled. Documenting a Referral Order In the Referrals Orders template in the tabbed template set, you can place or manage orders for referrals for other specialists, locations, therapies, and durable medical equipment (DME). Document Office Proc

Document Information in the Assessment/Plan Panel

Recommendations

Document Information in the Prenatal Visits Panel

Components of the Prenatal Detail - Obstetrics Template

Document Assessment/Plan in the OB Postpartum Template

Using the Assessments Tab

Add Diagnosis from Today’s Assessment to Obstetric Problems List

Add or Update Assessment Template

Document Information in the Prenatal Visits Panel

Components of the Prenatal Detail - Obstetrics Template

Document Assessment/Plan in the OB Postpartum Template

Using the Assessments Tab

Add Diagnosis from Today’s Assessment to Obstetric Problems List

Add or Update Assessment Template