Document Patient Goals
Before you begin
Ensure that you have selected the
Specialty
and
Visit Type
as
Care Management
.
You can record a patient's care management goals on the
Goals
panel. You can add, edit and remove goals.
On the
Plan/Intervention
tab, expand the
Goals
panel.
Click the
Goals reviewed/updated
option.
The Goal action options appear.
If setting new goals, click the
Set new goal(s)
option.
If the patient's care management goals have been met, click the
Met goals
check box.
If patient's goals have been modified, click the
Revised goal(s)
check box.
Record all the information that applies to the goal.
Enter
Goal statements
and click
Add.
The collected record appears in the grid below.
Do the following in the grid:
To update a goal, highlight the corresponding goal, make changes, and click
Update
.
To remove a goal, highlight the goal to be removed, and click
Remove
.
Recommendations
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NextGen® Adaptive Content Engine Help Enterprise 8
Identify Educational Material or Make Recommendations
Before you begin Ensure that you have selected the Specialty and Visit Type as Care Management. On the Plan/Intervention tab, expand the Education/Recommendations panel. Education/Recommendations Click the appropriate check box to identify the topic discussed with the patient. If the patient is to follow up with a care manager, click the Follow up w/ Care Manager advised check box. Patient instruction options appear. If the patient is to contact the care manager, click the patient to set up option. If the care manager is to contact the patient, click the Care manager to contact patient option. Optionally type comments in the Education/Recommendations comments area. Parent topic: Plan/Intervention Tab
NextGen® Adaptive Content Engine Help Enterprise 8
Add a Patient Goal to Address a Health Concern
You can add multiple goals to a single health concern. To add multiple goals, repeat this procedure for each goal. From the navigation bar, click Care Plan. The Care Plan template appears. Expand the Goals, Interventions and Outcomes panel. The Select a Health concern to document section appears with all previously added health concerns. Goals, Interventions and Outcomes panel Select a health concern from the list. The information about the selected health concern goal fields appears on the right. Goal details on the Goals, Interventions and Outcomes panel In the Goal field, type a goal description to address the health concern, or use Common Phrases. Indicate if the goal is a patient goal or a provider goal. Verify that the life cycle status of the goal is set to Active. You can also change the status. For Goal achieved, do one or more of the following: Select Yes, No, Goal not attainable, or No progress toward goal. Click the field below and then select an option from the list that a
NextGen® Adaptive Content Engine Help Enterprise 8
Plan/Intervention Tab
You can define various team members who are going to provide healthcare services to a patient and maintain patient circumstances using the Plan/Intervention tab. The Plan/Intervention tab consists of the following panels: Panel Description Care Coordination Team This panel enables you to define the various team members who are going to provide healthcare services to a patient. When defining team member, you identify the individual provider and the agency with which the provider is associated. Barriers to Care This panel enables you to record and track patient circumstances that may negatively impact the patient’s ability to comply with the requirements of the nursing care plan. History This panel lists all the nursing care plans that have been created for a patient. These plans can be created on the History panel. Interventions This panel lists the current interventions that have been defined for a patient along with the relevant data necessary to define the intervention. Progress This
NextGen® Adaptive Content Engine Help Enterprise 8
Enter New Therapy Goals for the Patient
Therapy goals are based on information documented for the reason for visit, History of Present Illness (HPI), and physical exam for the patient. Preconfigured therapy goals configurations are packaged with the system. Clients can add customized goals and modify or remove existing ones. Goals can be added, updated or removed. On the Objective template, on the Goals panel, click the Add button to launch the Therapy Goals template, which displays accumulated goals listed in the Available Goals grid. Therapy Goals Highlight a row in the Available Goals grid to select a goal. Click the Goal type field and select the type of goal from the picklist. The remaining fields display additional details for the goal. Click the Weeks field and select the number of weeks to reach the goal, if appropriate. Click Add. The Added goals grid displays the new goal. Click Save & Close to return to the Objective template. The information appears in the Goals panel. Parent topic: Patient Goals
NextGen® Adaptive Content Engine Help Enterprise 8
Record an Outcome for an Intervention
From the navigation bar, click Care Plan. The Care Plan template appears. Navigate to the Goals, Interventions and Outcomes panel. The Select a Health concern to document grid is populated with all previously identified health concerns. Select a health concern from the list. The selected health concern appears in the Health Concern field and the data entry fields for goals appear to the right. Select the goal that you are adding an intervention outcome for. The data for the selected goal populates the data entry fields to the right. Click the Interventions tab. The full Interventions tab appears with the previously entered interventions in the Select an Intervention to document grid. Click the intervention in the grid that you are reporting an outcome for. Click the Outcomes tab. The full Outcomes tab appears with the data entry fields for the outcome to the right. Goals, Interventions and Outcome Click the Outcome field and type a description of the outcome. Click the Outcome date fie
NextGen® Adaptive Content Engine Help Enterprise 8
Update a Health Concern Goal
You can update all the fields for a goal if the goal was created during the current encounter. You can update the following fields during subsequent encounters: Goal achieved Patient priority Provider priority Target Completion Comments Status From the navigation bar, click Care Plan. The Care Plan template appears. Navigate to the Goals, Interventions and Outcomes panel. Click the goal to be updated in the left grid. The system populates the fields to the right of the grid with the data from the selected record. Make any necessary changes to the data fields. Click Update. The system updates the goal. Parent topic: Add a Patient Goal to Address a Health Concern
