Document Information in the Prenatal Visits Panel

NextGen® Adaptive Content Engine Help Enterprise 8

Document Information in the Assessment/Plan Panel

The Assessment/Plan panel enables you to enter an assessment, generate the prenatal record, enter a follow-up appointment if not already done on the OB flowsheet, document which hospital the prenatal record must be sent to, and task to send the prenatal record to the hospital. The Prenatal Record button generates the cumulative Obstetric document for the pregnancy to date. At the first visit, it is important to generate the Prenatal Record to review all of the information for completeness and accuracy. After reviewing the Prenatal Record, the provider may note data that was not entered or view information that must be entered in the Problem/Detail list for easy viewing at subsequent visits. Select the Prenatal Detail tab Select the Assessment/Plan tab. Assessment/Plan panel To add an assessment, select Add/Update. Select any diagnosis in the Billing Diagnosis History section, the Clinical Problems section or the My Favorites section. Add or Update Asssessment The diagnosis is added to

NextGen® Adaptive Content Engine Help Enterprise 8

Review Optional Orders

You can place orders for the tests in the Optional Orders panel during any time of pregnancy. Open NextGen® Enterprise EHR. Open a female adult patient record, and then create an encounter. On the Intake template, and then select the specialty as Obstetrics and visit type as OB Prenatal. On the Prenatal Detail template, expand the Optional Orders panel. The associated lab orders appear in the grid. Optional Orders Double-click the test name to place the order through Historical Test - Quick Entry template. To review a single lab order result, do the following: Select the row where the lab order result is available. The Edit Test Interval window opens. Select the Reviewed check box, and then select Save & Close. The reviewed check mark appears. To review all lab orders with results, select the Reviewed check box. The reviewed check mark appears for all orders with results. To update the order obtained interval date range, select the row and update the details on the Edit Test Interval w

NextGen® Adaptive Content Engine Help Enterprise 8

Document Information in the OB Flowsheet

You can document the vital signs of the patient on the OB Flowsheet 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. Select the Specialty as Obstetrics and Visit Type as OB Prenatal. Select Prenatal Detail. The Prenatal Detail template opens. In the Prenatal Visits panel, select Add. The OB Flowsheet template opens. The gravidity, parity, estimated gestational age, blood type and Rh, and risk level become available if the information was already entered in the templates. When the OB flowsheet opens, the weight, blood pressure, pain level, and urine dipstick results appear if the details are entered on the Intake tab. Select the appropriate entries. Enter the weight of the patient in the Weight (lbs) field within the 4.409 – 1543.2 lb range. Note: If the value entered is not within the range, a message appears to indicate that the value entered is ou

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 Physical Exam in the OB Postpartum Template

Select the Postpartum tab. Select the Physical Exam panel. Do one of the following: Select the Postpartum Exam option from the left pane. Select the Additional link and select the Postpartum Exam option from the picklist. The Postpartum Exam template opens. Postpartum Exam Select the One Page Exam link. The GYN-PE template opens. Enter the applicable information in the General Exam section in the Postpartum Exam template . If you select the All others normal/negative check box, the Normal check box is selected for all the fields. Enter the applicable information in the Breast Exam section. Select the Breast Exam link. In Breast- Physical Exam select the All others normal check box, the Normal check box is selected for all the fields. Select the Genitourinary link. Enter any applicable information in the Genitourinary Female - Physical Exam template. Select Save & Close. Enter the applicable information in the Genitourinary Exam section. Enter comments in the Additional Physical Exam Co

NextGen® Orthopedic Suite Help 80.2.14.0

Document Pre-Operative History and Physical Examinations

You can review patient histories, document physical examinations, and add diagnosis details. On the Intake template, click the Non-Billable tab. The Navigation window opens. Select Pre-op H&P from the list, and click OK. The Pre-op H&P template opens. Note: The Patient is accompanied by field displays the data documented on the Intake template. You can change the value as needed. History panel on the Pre-op H and P template In the History panel, review the chief complaint, patient histories, medications, and allergies. Note: The fields in this panel are automatically filled with the data documented on the Intake template. You can document additional details or edit the details as needed. Enter the history of the present illness. In the Physical Exam panel, select an option from the left navigation bar, and document the physical examinations. Note: You can add or edit details in the following grids as needed. Vitals Today's Internal Radiology Orders Injections Outside Diagnostic Studies

Document Information in the Prenatal Visits Panel

Recommendations

Document Information in the Assessment/Plan Panel

Review Optional Orders

Document Information in the OB Flowsheet

Components of the Prenatal Detail - Obstetrics Template

Document Physical Exam in the OB Postpartum Template

Document Pre-Operative History and Physical Examinations

Document Information in the Assessment/Plan Panel

Review Optional Orders

Document Information in the OB Flowsheet

Components of the Prenatal Detail - Obstetrics Template

Document Physical Exam in the OB Postpartum Template

Document Pre-Operative History and Physical Examinations