Document Physical Exam in the OB Postpartum Template

NextGen® Adaptive Content Engine Help Enterprise 8

Document Reason for Visit in OB Postpartum template

Select the Postpartum tab. Open the Reason for Visit panel: Enter any additional text in the Introduction field. The Introduction field automatically displays a statement describing the patient's age, gender, and reason for visit. The same statement appears on the Reason for Visit panel of the SOAP template. To view the nurse/MA comments, select the Intake Comments link to open the Intake Comments template. Do one of the following: Select the postpartum check reason for visit from the left pane. Select the Additional / Manage link and select the postpartum check option in the Reason for Visit template. Open the Postpartum Details – HPI template and enter the required information. To enter information in the Diagnostic History Entry template, select Diagnostics. To view the chief complaint and reason for visit in the Hopi Notes template, select Comments. Document Postpartum Details You can enter information in the Postpartum Details -HPI template Parent topic: Document the OB Postpartum

NextGen® Adaptive Content Engine Help Enterprise 8

Document Pregnancy Outcome in the OB Postpartum Template

Select the Postpartum tab. In the Pregnancy Outcome panel, select Add/Update. The Pregnancy Outcomes template opens. Enter the applicable information in the Pregnancy Outcomes template. The entered information displays in the Pregnancy Outcome grid. Verify the parity values are correct. Pregnancy Outcome grid Select the OB Problem List link. The OB Problem List template displays with the most recent pregnancy information in a new grid view. You cannot edit the information in the OB Problem List template. Select an entry in the Pregnancy Outcome grid. To generate the pregnancy outcome document , select the Pregnancy Outcome Document button. Note: The Details text box is read-only and no comments can be entered here. Parent topic: Document the OB Postpartum Visit Template

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

Document the OB Postpartum Visit Template

The OB Postpartum Visit template provides users with an easier way to document a routine OB postpartum visit. The template enables you to document the routine OB postpartum visit without opening other templates. If you need to access other templates an easy access to those additional templates is provided directly from the OB Postpartum Visit template. Wherever possible, the OB Postpartum Visit template fields maps to their corresponding fields in the other templates. The Postpartum template contains the following seven panels: General Reason for Visit Pregnancy Outcome Vital Signs Physical Exam Assessment/Plan Return Appointment Postpartum template Enter Information in the OB Postpartum Visit Template You can enter information in the OB Postpartum Visit template. Document Reason for Visit in OB Postpartum template You can enter information in the Reason for Visit panel on the OB Postpartum template Document Pregnancy Outcome in the OB Postpartum Template You can document pregnancy out

NextGen® Adaptive Content Engine Help Enterprise 8

Document Pap Physical Exam Details for Annual Well Women Visits

You can document the physical exam details of an annual-well-women visit with a Pap specimen obtained and sent to the lab. Open NextGen® Enterprise EHR. Open the SOAP template. In the Physical Exam panel, select One Page Exam. The One Page - Physical Exam template opens. Select the GYN Exam link. The GYN - PE template opens. GYN - PE To indicate normal findings for each system, select the Normal check box. To add any abnormal information, select the corresponding Findings field. In the STI Screenings section, select Yes for Pap. To document the Pap specimen collection, Select the Detail link. The Pap Detail-PE template opens. Pap Detail-PE Enter the necessary details in Pap Detail PE, and then select the diagnosis and type of Pap. Select Save & Close. The Pap Detail-PE template closes. The Submit breast exam to Superbill check box is selected by default. Note: If a screening exam is performed, the system automatically submits the appropriate assessment and G-code when the Submit breast

NextGen® Adaptive Content Engine Help Enterprise 8

Document a Physical Exam

The One Page Exam template is used to document a physical exam. Physical Exam panel You can examine a patient and document the information in the Physical Exam panel on the SOAP template. In the Physical Exam panel, you can, Use the One Page Exam to document the exam on the Gyn-PE template. On the Gyn-PE select the Normal check box to indicate normal findings for each system or click the Findings field to add any abnormal findings. Use other single system exam and its submenu in the left pane to document the corresponding exam details. When you click the single system exam or its submenu, the respective template opens. Use the Office Diagnostics button to document or review diagnostics and to place orders for the tests. Use the Quick Load or Quick Save button to load a saved default set or save a new default set. Use the Physical Exam History button to copy previous physical exam records to the current encounter. Document a Breast Palpation Physical Exam You can document the breast pal

Document Physical Exam in the OB Postpartum Template

Recommendations

Document Reason for Visit in OB Postpartum template

Document Pregnancy Outcome in the OB Postpartum Template

Document Assessment/Plan in the OB Postpartum Template

Document the OB Postpartum Visit Template

Document Pap Physical Exam Details for Annual Well Women Visits

Document a Physical Exam

Document Reason for Visit in OB Postpartum template

Document Pregnancy Outcome in the OB Postpartum Template

Document Assessment/Plan in the OB Postpartum Template

Document the OB Postpartum Visit Template

Document Pap Physical Exam Details for Annual Well Women Visits

Document a Physical Exam