Encounter Diagnosis

NextGen® Adaptive Content Engine Help Enterprise 8

Treating Assessments

The grid in the Treating Assessment section enables you to add assessments for therapy treatments. The treating assessments may be the same as the encounter or ordering diagnoses, or they may be more general. For example, the treating diagnosis may be “pain hip/pelvic” with one diagnosis code, while the encounter diagnosis or ordering assessment may be “sprain hip/thigh” with a different diagnosis code. The Treating Assessment section appears on multiple templates throughout the Physical Therapy workflow and maintains the same functionality. Add a Treating Assessment Edit a Treating Assessment Remove a Treating Assessment Parent topic: Documenting General Patient information

NextGen® Adaptive Content Engine Help Enterprise 8

Add an Encounter Diagnosis

On the Subjective template, go to the General panel and click Add under the Encounter Diagnoses section. Click the Add common assessment link to view the common assessments for Physical Therapy, and do one of the following actions: If the required assessment is available on the Common Assessment window, click the assessment link, select an appropriate description from the resulting list, click OK, and then click Save & Close. If the required assessment is not available on the Common Assessment window, click the Diagnosis Code Lookup link, search for and select a diagnosis, and then click Select. Select the Show Historical assessments check box to display the patient's historical assessments in the grid. Parent topic: Encounter Diagnosis

NextGen® Adaptive Content Engine Help Enterprise 8

Assessments Panel

Encounter Diagnoses and Treating Assessments can be reviewed and updated on the Assessments panel on the PT Finalize template. The Assessments panel functions the same way as the Diagnosis panel on the Home Page and the Treatment Log templates. The Encounter Diagnoses grid displays current encounter diagnoses. The Treating Assessment grid may contain the same diagnoses as the Encounter Diagnoses grid or they may be different. Assessments Parent topic: Finalize Template Related concepts Encounter Diagnosis Treating Assessments

NextGen® Adaptive Content Engine Help Enterprise 8

Physical Therapy Home Page Template Details

The practice can customize the panels displayed on the Home Page - Physical Therapy template. The following table describes the panels on the template. Panel Description Diagnosis Lists all the assessments to be included in orders and billing. You can view billing assessments for the current encounter, including ICD codes. Goals Displays patient's therapy goals documented by the provider in the Therapy Goals template. Treatment History Displays the treatment hisory details related to the patient. Historical PE Displays the Historical PE details. Treatment Log Displays the patient's treatement details by encounter. Lists the patient's encounter diagnosis, treating assessments, and a history of treatments in a flowsheet format, organized by the encounter date. Allergies Lists the allergies associated with a patient. Medications Lists the patient's current medications. Orders Lists the patient's labs, diagnostics, immunization, surgical procedures, and referral orders. Parent topic: Patie

Help Guide for NextGen® Enterprise PM 8

Encounter-Level Diagnosis Codes

Diagnosis codes are typically entered during charge posting. Charge-level diagnosis codes then display in the ICD-CM section on the General sub-tab on the Encounters tab in the Patient Chart. After charge posting, you can add additional encounter-level diagnosis codes, if needed. You can also add encounter-level diagnosis codes prior to charge posting, so they default to each charge during charge posting. Note: Diagnosis codes added to an appointment from the Ins/Diag tab in the Add/Modify Appointment window automatically default to the ICD-CM section on the General sub-tab in the Patient Chart > Encounters tab when the appointment is checked-in and the encounter is created. Add Encounter-Level Diagnosis Codes You can add diagnosis codes at an encounter-level for a patient. Select an Admitting Diagnosis for UB Claims You can use the admitting diagnosis as an institutional claim to indicate the patient's primary diagnosis at the time of inpatient admission. Enter Present on Admission In

Help Guide for NextGen® Enterprise PM 8

Remove Encounter Diagnoses from an Encounter to be Deleted

Access the Patient Chart. Select the Encounters tab, and then the General sub-tab. In the ICD-CM section, select the Open Record button. The Diagnosis Selection window appears. From the Selected ICD-CM Codes section, select a diagnosis code to be deleted. Select the blue left arrow button to remove the code from the encounter. A prompt appears asking to confirm the removal of this diagnosis. To remove the code, select OK. One of the following occurs: If the diagnosis code is not associated with charges, it is removed from the encounter. If the diagnosis code is associated with a charge, then a prompt appears stating that this diagnosis code is used on a charge and that it cannot be removed. Repeat steps 4-6 for additional diagnosis codes to be deleted. To save changes and close the window, select OK. Parent topic: Delete Encounters

Encounter Diagnosis

Recommendations

Treating Assessments

Add an Encounter Diagnosis

Assessments Panel

Physical Therapy Home Page Template Details

Encounter-Level Diagnosis Codes

Remove Encounter Diagnoses from an Encounter to be Deleted

Treating Assessments

Add an Encounter Diagnosis

Assessments Panel

Physical Therapy Home Page Template Details

Encounter-Level Diagnosis Codes

Remove Encounter Diagnoses from an Encounter to be Deleted