Entering and Modifying Assessments

NextGen® Adaptive Content Engine Help Enterprise 8

Entering Assessments, Impressions, Differential Diagnoses, and Associated Details

On the Assessment / Plan Details template, the provider selects an assessment and then enters any pertinent comments, differential diagnoses, plan details, provider details, or today's orders with the option to use My Phrases or Common Phrases (practice-wide phrases), and Follow-Up. Entering information in A/P Details tab is optional. The A/P Details tab includes the following sections: Today's Assessment grid: You can add, edit, sort, and remove rows. The columns include the diagnosis priority number (#), Description, Code, and Status. Impression/Comments memo field: You can enter text, record audio, and access My Phrases. The data entered here also appears in the Assessment / Plan panel. You can select Comments link to open the A/P Details tab directly from Assessment / Plan panel to update the comments. The first 215 characters entered as impression details can be reviewed in the Problems module, Billing ICD List tab and Note field. Differential Diagnosis field: You can enter text o

NextGen® Adaptive Content Engine Help Enterprise 8

Using the Assessments Tab

The Assessments tab in the My Plan template set houses the Add or Update Assessment template. The grids on the Assessments tab can be filtered. For example, in the Billing Diagnosis History section, selecting the Show Chronic only check box displays only those diagnoses that are not acute. Selecting the option to Add Assessments on 1 click speeds up the documentation process by including the diagnosis description and code for Today's Assessment in the grid and Problems module without having to click Add/Update. The Medications or Immunizations links can be used at any time during the encounter to access the associated module. Open the Assessments Tab Document an Assessment You can document an assessment on the Add or Update Assessment template. Shared Working Assessment The group of templates that share the selected assessment for the patient. Change the Order of Assessments in the Grid Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the To

NextGen® Adaptive Content Engine Help Enterprise 8

Select an Assessment from Billing Diagnosis History

On the Add or Update Assessment template, Billing Diagnosis History section, select an existing diagnosis from the grid. To open the Common Assessment template, click Add common assessment. Add or Update Assessment The template opens to the page associated with the currently selected Specialty and gender and age of the patient. To view a different page, click the Common assessments field to open a picklist of assessment page options. Common Assessment Click Save & Close to close the Common assessment page. To open the diagnosis search window, click Diagnosis Code Lookup. For more details on searching for diagnoses in the window, go to NextGen Healthcare Success Community to download the latest Problems Module User Guide for NextGen® Enterprise EHR. Select the line item in the grid to fill the ICD description and ICD Code fields. Continue documenting the assessment on the Assessments tab. Convert ICD Codes in the Billing History Parent topic: Document an Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Add Assessments or Plans

Open NextGen® Enterprise EHR. Open the SOAP template. Click the Assessment/Plan panel. From the left pane, click an assessment category link. The diagnosis search window displays a list of diagnoses for the category selected. Select an appropriate diagnosis and then click Select. The diagnosis has been added to and displayed in the grid with the letter “D” and lines for A and P. Assessment/Plan Panel Click the A row in the grid for a diagnosis. The Assessment And Plan template opens. Assessment And Plan Template Note: Certain diagnosis requires you to choose a category before documenting the details. This allows the appropriate assessments that match the ICD-10 code to display. To enter an assessment or plan, do one of the following: Click Type an assessment below the Status field. Click Type a Plan below the Plan Type field. Note: To use phrases, click the My Phrases link and then select an option from the list. For more information, go to NextGen Healthcare Success Community, and dow

NextGen® Adaptive Content Engine Help Enterprise 8

Change the Order of Assessments in the Grid

Because only the first 12 line items are available for billing, providers may want to ensure that certain assessments are included in the top 12 rows for the list. Open NextGen® Enterprise EHR. On the Assessments tab, select Sort to open the Reorder Assessments template. Reorder Assessments In the Existing Sort Order grid, select the row that you would like to be the first in the list. That selection becomes number 1 in the New Sort Order grid. Continue to select the available assessment rows until you have them in the desired order. If you select a row in error, select Undo Last. To start over, select Undo All. When the desired order fills in the New Sort Order grid, select Save & Close. Parent topic: Open the Assessments Tab Parent topic: Access the Add or Update Assessment Template Parent topic: Using the Assessments Tab Parent topic: Add or Update Assessment Template Related tasks Document an Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Add Orders on the Order Management Template

You can add orders from the Order Management template. Open NextGen® Enterprise EHR. On the Home Page template, select the Order Management link. The Order Management template opens. Order Management If orders are not available in the grid, select Add. The My Plan template opens. Note: If you select the Launch My Custom Plan (ord_my_custom_plan) check box on the Practice Configuration practice template, the My Custom Plan template opens. For more information on the My Custom Plan template, go to NextGen Healthcare Success Community, and download the latest My Plan Template Set User Guide forNextGen®Adaptive Content Engine. If necessary, select an assessment in the Today's Assessment grid. The My Plan template is part of a group of templates that use the last assessment or diagnosis selected on any of the templates in the group as the working assessment. The system defaults to the current working assessment. You can select another assessment, which becomes the new working assessment tha

Entering and Modifying Assessments

Recommendations

Entering Assessments, Impressions, Differential Diagnoses, and Associated Details

Using the Assessments Tab

Select an Assessment from Billing Diagnosis History

Add Assessments or Plans

Change the Order of Assessments in the Grid

Add Orders on the Order Management Template

Entering Assessments, Impressions, Differential Diagnoses, and Associated Details

Using the Assessments Tab

Select an Assessment from Billing Diagnosis History

Add Assessments or Plans

Change the Order of Assessments in the Grid

Add Orders on the Order Management Template