Documenting Patient Encounters for Dermatology Visits

NextGen® Adaptive Content Engine Help Enterprise 8

Documenting Obstetrics Visits Encounters

The Obstetrics User Guide for NextGen® Adaptive Content Engine is intended for Obstetrics medical professionals, such as providers, nurses, and front office staff, responsible for documenting and processing patient information. You can use the NextGen® Adaptive Content Engine templates to document encounters on the OB Prenatal- Initial and OB Postpartum visit encounters. When you select the OB Prenatal – Initial visit type, the following navigation tabs display: Intake Gestational Age Histories Education Prenatal Detail SOAP Checkout Note: The above navigation tabs also display during nurse visits and subsequent prenatal visits. However, the Office Visit – OB, Virtual Visit Telephone, and Virtual Visit Video visit types display all the above navigation tabs except Gestational Age; the Chart Abstraction, Chart Update - OB, No-Show, and Consult visit types display all the above navigation tabs except Checkout. For the Patient Communication visit type the Telephone Call, Provider Test Act

NextGen® Adaptive Content Engine Help Enterprise 8

Basic Configurations

The section includes instructions to set template preferences, add the required links on the templates, configure the management plans, medication inventory, and so on. For more information about the common configuration options, go to NextGen Healthcare Success Community, and download the Getting Started User Guide forNextGen®Adaptive Content Engine. Enable the Cancer Registry Option on Practice Configuration Enable Free Text Option on Practice Configuration Template You can enable the free text option for documenting the cancer staging details on the Practice Configuration template. Create a New Custom DB Picklist Configure a Custom DB Picklist Configure Cancer Type Fields and TNM Values You can configure the cancer type fields and TNM (Tumor, Node, and Metastasis) values of the cancer staging system by creating a custom DB picklist on the Custom DB Picklists template. Pre-Configuration of MA Intake in the System Template Set Up Disclosure Statements for SAMHSA The configuration in t

NextGen® Adaptive Content Engine Help Enterprise 8

General Dermatology Workflow

The general dermatology workflow offers a broad framework for conducting a dermatological visit. The workflow provides guidelines for conducting a comprehensive patient encounter using the Dermatology specialty of NextGen® Adaptive Content Engine. You can modify this workflow to meet your own specific needs. In addition, your office staff can be organized differently and their duties may be defined differently. Regardless of who executes each steps, the functions remain the same. The general office and virtual visit workflow includes: Intake staff workflow Provider workflow Checkout staff workflow Note: The instructions provided for office visit are also applicable for virtual visits. Intake Staff Workflow The intake staff can use the Intake template to document a patient's chief complaint, vital signs, medications, allergies, standing orders, and various other findings. Provider Workflow You can review the patient's medical summary details on the Home Page template and then proceed to

NextGen® Adaptive Content Engine Help Enterprise 8

Substance Use Disorder Disclosure in Documents and Reports

You can include the disclosure for Substance Abuse and Mental Health Services Administration (SAMHSA) 42 CFR Part 2 provisions in the generated documents and reports. If your practice provides treatment for substance use disorder, you have to include the long form or short form of disclosure for Substance Abuse and Mental Health Services Administration (SAMHSA) 42 CFR Part 2 provisions in the generated documents and reports. You need to configure the Record contains substance use disorder information check box on encounter level templates by selecting the long form or short form of disclosure on the Practice Configuration practice template. The check box appears on the Intake, Histories, SOAP, Finalize, and Checkout templates. For more information on configuring SAMHSA, go to NextGen Healthcare Success Community, and download the Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. If you select the Record contains substance use disorder information check box,

NextGen® Adaptive Content Engine Help Enterprise 8

Dermatology

You can use the templates for dermatology to document information related to patient encounters specific to dermatology. Documenting Patient Encounters for Dermatology Visits A brief information on dermatology patient encounter workflow. Graphical Exam Tool (GET) You can streamline your workflow and eliminate the need to use the SOAP template using the Graphical Exam Tool (GET). Predominant Procedures for Provider Various dermatological encounters, visit types and important functionality are explained. General Dermatology Workflow You can use the NextGen® Adaptive Content Engine dermatology specialty framework templates to document the encounter details for different visit types of a dermatology patient. Mohs Surgery You can document Mohs surgery performed for skin cancer treatment of a patient. Related concepts Documenting Patient Encounters for Dermatology Visits Graphical Exam Tool (GET) Predominant Procedures for Provider General Dermatology Workflow Mohs Surgery

NextGen® Adaptive Content Engine Help Enterprise 8

Review of SOAP Details by Provider

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, assessment plans, and provider communications. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan You can select the Record contains substance use disorder information check box on the SOAP template header to include the long or short form of disclosure for Substance Abuse and Mental Health Services Administration (SAMHSA) 42 CFR Part 2 provisions in the generated documents and reports. You can use Quick Notes to save the documented SOAP findings as a default set that can be used in future encounters. For more information on these settings, go to NextGen Healthcare Succes

Documenting Patient Encounters for Dermatology Visits

Recommendations

Documenting Obstetrics Visits Encounters

Basic Configurations

General Dermatology Workflow

Substance Use Disorder Disclosure in Documents and Reports

Dermatology

Review of SOAP Details by Provider

Documenting Patient Encounters for Dermatology Visits

Documenting Obstetrics Visits Encounters

Basic Configurations

General Dermatology Workflow

Substance Use Disorder Disclosure in Documents and Reports

Dermatology

Review of SOAP Details by Provider