Documenting General Patient information
The
Subjective
template enables you to document information such as surgical data, authorized visits, reason for visit and history of present illness, vital signs, and comments.
Enter or Review Surgical Data, Authorized Visits, and Diagnosis
Encounter Diagnosis
Treating Assessments
Recommendations
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NextGen® Adaptive Content Engine Help Enterprise 8
Histories Template
Patient history information is documented on the Histories template for a new patient, and reviewed and updated for an existing patient. Histories Patient's Problem List You can manage a patient's problems. Patient's Medical History The Medical/Surgical/Interim panel enables you to document the medical or surgical history of the patient. Patient's Diagnostic Tests and Results You can document a patient's diagnostic tests and the associated results. Patient's Family History You can document the family history of the patient in the Family panel on the Histories template. Document the Social History of the Patient You can document the social history of a patient from the Social panel on the Histories template. Parent topic: Physical Therapy
NextGen® Adaptive Content Engine Help Enterprise 8
Objective Template
The Objective template is used by the provider to review and update previously documented information about the patient such as surgical procedure dates, reason for visit, History of Present Illness (HPI), and vital signs. The provider then proceeds to document detailed information for the encounter, such as a physical exam, assessment and plan, observations, goals, treatment, edema, and wounds and incision care. The Objective template includes the following panels: Objective General Panel Document the Reason for Visit Physical Exam Panel Assessment/Plan Panel Add Observations Patient Goals Physical Therapy Treatment Panel Document Edema Details Document Wound Progression/Healing Vital Signs Panel Documents and Printing Parent topic: Physical Therapy
NextGen® Adaptive Content Engine Help Enterprise 8
General Physical Therapy Workflow
The Physical Therapy tabbed template set presents a general workflow for documenting the patient history, physical therapy orders, physical exam, goals, and treatment for physical therapy encounters. Patient's Summary Review for Physical Therapy by the Intake Staff If required, the intake staff can review the patient's historical information documented in the previous encounters on the Home Page - Physical Therapy template. Access Home Page - Physical Therapy You can use the Templates module to access the Home Page - Physical Therapy template. Adding and Reviewing Allergies You can add and review the allergy details associated with a patient in the Allergies panel. Viewing Patient Medications You can view the patient's medications in the Medications panel on the Intake template. Parent topic: Physical Therapy
NextGen® Adaptive Content Engine Help Enterprise 8
Patient's Summary Review for Physical Therapy by the Provider
The information documented by the nursing staff on the Intake template displays on the Home Page template for the provider's review. You can update information on the Intake and SOAP templates. NextGen Healthcare recommends training providers to begin the visit on the Home Page - Physical Therapy template. Physical Therapy Home Page Template Details You can review the patient information on the Home Page - Physical Therapy template. Parent topic: Physical Therapy Related reference Physical Therapy Home Page Template Details
NextGen® Adaptive Content Engine Help Enterprise 8
Enter or Review Surgical Data, Authorized Visits, and Diagnosis
The General panel enables you to enter or review surgical data, authorized visits and diagnosis. Most of the information that you document in the General panel are one-time entries. From the Subjective tab, expand the General panel, and then select one of the patient type options, such as Established patient or New patient. General Note: The Established patient option is automatically selected if a previous encounter exists for the patient. To select the relationship of the person providing the details for the patient, click the Historian field. Enter the Onset date and the Start of care date. Note: The Referring provider field displays the provider name entered at the encounter level. Select the surgical procedure to be performed. Select No or Yes for Patient awareness of diagnosis and prognosis. Note: The Total number of visits, Today’s visit number, and Total authorized visits are read-only and automatically display the visit numbers based on current physical therapy orders on the P
NextGen® Adaptive Content Engine Help Enterprise 8
Physical Therapy
You can use the NextGen® Adaptive Content Engine to document visit types for both Physical Therapy and Occupational Therapy. Documenting Physical and Occupational Therapy Encounters Configuration Options Physical Therapy Navigational Links General Physical Therapy Workflow Documenting General Patient information Histories Template Patient's Summary Review for Physical Therapy by the Provider You can review the patient information documented during the previous encounters. Objective Template Finalize Template This topic describes the purpose of the Finalize template. Treatment Log Template Overview of the Checkout Staff Workflow You can review and generate documents of a patient's checkout process. Related concepts Documenting Physical and Occupational Therapy Encounters Physical Therapy Navigational Links General Physical Therapy Workflow Histories Template Patient's Summary Review for Physical Therapy by the Provider Objective Template Finalize Template Treatment Log Template Related
