Document Postoperative Concerns

You can document the type and date of postoperative complication(s) specifically for Quality Reporting reasons in A/P Details in the Assessment / Plan panel on SOAP.

1. Open NextGen® Enterprise EHR.
2. On the Add or Update Assessment template, select A/P Details.
3. On the Assessment Plan Details template, select the Postoperative Quality Reporting link.
   The Postoperative Quality Reporting template opens.

   

4. To select the appropriate initial procedure performed, select the Patient Procedures or Postoperative Quality Measure search method.
   • Patient Procedures lists all the procedures that are added to the procedures module based on the codes from the service category. The service date should be less than or equal to the encounter date.
     Note: You can add or remove codes from the Postoperative Quality Measures list on the Modify Service Category Information template in File Maintenance. For more information on how to manage service categories, go to NextGen Healthcare Success Community, and download the latest Office Diagnostics Setup and Management Practice Template forNextGen®Adaptive Content Engine.
   • Postoperative Quality Measure displays a list of all the codes and procedures from the service category.
     

5. To capture the Initial surgical procedure details, enter Date, Code, and Description details.
   Note: When you select the appropriate code/procedure, the application automatically fills the other field (procedure/code). For Postoperative Quality Measure search method, you need to select the date of the initial surgical procedure in the Date field. For Patient Procedures search method, the application automatically fills the Date field automatically when you select the code/procedure.
   Note: If you select in the Code field, the code(s) are available in the first column and the procedure description(s) in the second column. If you select in the Description field, the procedure description(s) are available in the first column and the code(s) in the second column. The service date is listed in a descending order.
6. To document the three postoperative concerns required for the regulatory measure, select No or Yes for the following postoperative complications:
   • Surgical site infection (SSI) within 30 days after operation
   • Unplanned hospital readmission within 30 days of the principle procedure
   • Unplanned reoperation within the 30 day postoperative period
7. If you select Yes for any of the postoperative complications, then a mandatory Date field appears. Select the appropriate date for the postoperative complication.
   

8. Select Save & Close.
   The color of the Postoperative Quality Reporting link changes to magenta.

   Note: When you reopen the Postoperative Quality Reporting template after saving it, a message appears at the bottom of the template to confirm the changes that are saved. You can select Clear All to clear the data on the Postoperative Quality Reporting template.