Document Transitioning into Care from the Care Management Specialty

You can document transitioning into care from the Care Management specialty.

1. Open NextGen® Enterprise EHR.
2. Select a patient and open an encounter.
3. Open the Intake template.
4. Select Specialty as Care Management and Visit Type as Care Management.
   The Cm Care Transitions template opens.

   

5. On the General panel, do one of the following:
   • Click the Encounter Type field to open a list of transitional care encounter types and then select an encounter type from that list.
   • Click the blue arrow to the right of the Encounter type field to open the interim history data list and then select a past encounter from the interim history data.
6. Click the PCP field.
   If there is no PCP selected in the patient chart, the Modify Patient Information template opens, enabling you to select a PCP.
   The field populates with the Primary Care Practitioner established in the patient's demographics.
7. Click the Case Manager field and select a case manager from the list.
8. Click the Historian field and then select the relationship of the named historian to the patient from the Relationships list.
   Note: There is a secondary Historian field in case you speak to more than one historian.
9. Click the Reason for Referral (to Care Management) field and select a reason for the case being transferred to Care Management.
10. Click the Admitted to field and select a facility or residence where the patient had been originally admitted.
11. If the patient had been released to a facility, click the Facility field, and select the appropriate facility.
12. Click the Date field, and select the date when the patient had been admitted.
13. Click the From field, and select the facility the patient had been admitted from.
14. Click the Discharged to field, and select the facility the patient had been discharged to.
15. Do one of the following:
    • Click the Date field to open the calendar and then select a discharge date.
    • Click the blue arrow to the right of the Date field to open the interim history data list and then select a date from the interim history data.
    Note: An icon appears to the right of the date field in the following scenarios:

    • When you select a discharge date, but do not enter an Initial Communication type or date fields
    • When the initial communication date is more than two business days post the discharge date.
16. Click the first Discharge diagnosis field and then select a discharge diagnosis from the diagnosis search screen.
    If you have more than one diagnosis, use the additional three fields.
17. Click either Yes or No to answer the following questions:
    • Previous hospital admission in last 30 days?
    • Follow up on pending tests or treatment performed?
    • Education provided to patient/family/caregiver?
    • Community resource needs accessed, such as home health, assisted living, hospice and/or support groups?
    • Discharge summary or continuity of care document obtained and reviewed?
    • DME needs assessed and orders completed if needed?
    • Referral needs assessed and completed if needed?
    When you complete all the entries, a row has been added to the Care Management Summary grid.