Document the Details for an Annual Well Woman Visit

NextGen® Adaptive Content Engine Help Enterprise 8

Document Breast HPI

The HPI - Breast Concerns template enables you to document information regarding breast complaints. Open the Intake template. In the Reason for Visit panel, select Breast Concerns in the left pane. Note: If the Breast Concerns reason for visit option is not listed in the left pane, you can select Additional / Manage, and then select Breast Concerns to add the reason in the Reason for Visit grid. The HPI - Breast Concerns template opens. HPI - Breast Concerns template Document details in the following fields: Concern Status Location Onset Timing Quality Context Modifying Factors Associated Signs and Symptoms ROS Enter your comment in the Comment field. Select Save and Close. Parent topic: Document Reasons for a Patient's Visit

NextGen® Adaptive Content Engine Help Enterprise 8

Document Female Urogenital

The HPI-Female Urogenital template enables you to document a female patient's urogenital concerns and symptoms. Open the Intake template. In the Reason for Visit panel, select Gyn problems in the left pane. Note: If Gyn problems reason is not listed in the left pane, you can select Additional / Manage, and then select Gyn problems to add the reason in the Reason for Visit grid. The HPI - Female Urogenital template opens. HPI - Female Urogenital template Document details in the following fields: Concern Status Duration/Timing Frequency Status Quality Severity of Bleeding Modifying Factors Associated Signs and Symptoms ROS Enter your comments in the Comment field. Select Save and Close. Parent topic: Document Reasons for a Patient's Visit

NextGen® Adaptive Content Engine Help Enterprise 8

Document Contraception Information

Open the Intake template. Expand the Reason for Visit panel. Select Contraception as the reason for the current visit. The Contraception – HPI template opens, and contraception appears in the Concern field. Contraception – HPI template To indicate a follow-up visit for contraception, select the Follow Up check box. The Concern field is updated to Follow-up of contraception. Follow up visit indication in the Contraception – HPI template Document the following information: Current and desired birth control method Reason for no birth control (at Intake) Desired birth control method Pros and cons of the current method Secondary conditions the patient is hoping to improve with birth control Previous methods, the age when the methods were used, and their responses Methods the patient does not consider and why If the patient is currently pregnant If the patient would like to get pregnant in the next year and the time frame If the patient has had unprotected intercourse within last five days o

NextGen® Adaptive Content Engine Help Enterprise 8

Reason for Visit for Well Child

You can use the Reason for Visit panel on the Pediatric SOAP template to review and update the reasons for visit added during the intake process. The Well child hpi appears on the grid automatically if you select Well child for Visit Type. Reason for Visit In addition to documenting the specialty specific reason for visit available in the left pane, you can also document a well child visit on the a generic HPI template by selecting Well child or Well child HPI in the Reason for Visit panel. In the Reason for Visit panel, you can: Review and update the social history of the patient using the Pediatric Social History link. Open the Interval History- Nutrition template using the Nutrition/Elimination link. Document substance use, psychiatric, placement, sexual practices, and child abuse history of the patient using the Confidential History link. Document the Well Child Reason on the Generic HPI Template You can document the reason for well child visit on the generic HPI template. Document

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

Overview of Well Child Visit

You can use the Well Child visit type to document routine checkups for a pediatric patient. Using the Well child visit type, you can document a history of present illness, child development history, anticipatory guidance, and various screening tests. Well child visit type The Well child encounter workflow is similar to the Office Visit workflow, with the exception that the Pediatric SOAP template is available in place of SOAP template. Intake staff begins the visit by selecting Pediatrics or Family Practice for the Specialty and Well child for Visit Type on the Intake template. Intake staff then documents all the necessary details of the visit in the Intake and Histories tabs, and generates Intake Note. Provider reviews the details documented by the medical assistant and selects the Pediatric SOAP tab to proceed with a comprehensive review and documentation of the well child visit. Note: The Pediatric SOAP template is also available for other specialties in the Templates module, but th

Document the Details for an Annual Well Woman Visit

Recommendations

Document Breast HPI

Document Female Urogenital

Document Contraception Information

Reason for Visit for Well Child

Document Pap Physical Exam Details for Annual Well Women Visits

Overview of Well Child Visit

Document Breast HPI

Document Female Urogenital

Document Contraception Information

Reason for Visit for Well Child

Document Pap Physical Exam Details for Annual Well Women Visits

Overview of Well Child Visit