Histories Template

Section	Description
Problem List	You can view, add, modify and retrieve patient's clinical problems and chronic conditions.
Medical/Surgical/Interim	You can document the patient's problem list and social, medical or surgical, diagnostic study, and family histories.
Diagnostics Studies	You can document the patient's diagnostic tests and its associated results.
Family	You can document the family history of the patient.
Social	You can document the social history of an adult or a pediatric patient. The categories in the social history includes tobacco/vaping use, alcohol/caffeine, lifestyle, occupation and so on.

NextGen® Adaptive Content Engine Help Enterprise 8

Documenting Social Details of Pediatric Patients

You can document social details of a pediatric patient in the Social panel. Section Description Tobacco/Vaping Use You can document the passive smoke exposure details of a pediatric patient. Relationships You can document child care provider details and relationship information of the patient. Home Environment You can document the patient's home environment and safety information. Education You can document the patient's education, sleep, activities, and any recent travels details. Nutrition/Elimination You can document the patient's nutrition, elimination, body image and dental care information. Comments You can add your comments or additional information related to pediatric social history. For comprehensive documentation of the patient's nutrition details, the following templates open based on the patient's age: Interval History - Nutrition birth- 12 mo for 0 to 12 months Interval History - Nutrition 1 to 4 yr for 1 to 4 years Interval History Nutrition Over 5 yr for 5 years or olde

NextGen® Adaptive Content Engine Help Enterprise 8

Dental

You can use the templates for Dental to document information related to patient encounters specific to dental care. Documenting Dental Patient Encounters You can use the Home Page and Histories templates in NextGen Adaptive Content Engine to document the encounter details of a dental patient. Dental Home Page You can review and document the summary of a patient on the Home Page template. Histories Template The Histories template enables you to document a patient's social history, problem list, medical or surgical history, diagnostic study history, and family history. Related concepts Documenting Dental Patient Encounters Dental Home Page Histories Template

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

Add Social History

You can add the social history of a patient in the History Summary panel on the Intake template and in the Social panel on the Histories template. Open NextGen® Enterprise EHR. To document the social history details, do one of the following: In the History Summary panel on the Intake template, select Social, select the relevant option in the list and Add/Edit. On the Histories template, expand the Social panel, select the relevant option, and then select Add/Edit. The social history template opens. Document the reported history information. Select Save & Close. Categories in Social History You can use different sections in the Social history to document the history of a patient. Patient's Tobacco Use Information You can document the patient's current or past tobacco use information. Document the Patient's Status You can document the status of a patient on the Social History - Status template. Screen for Future Fall Risk You can document the patient's risk for falls. Document Occupation

NextGen® Adaptive Content Engine Help Enterprise 8

Documenting the Patient History Summary

You can add, update, delete, and review a patient's history summary details from the History Summary panel. You can document a patient's history details in the History Summary panel in the following categories: Past Medical/Surgical Interim Social Family Diagnostic The History Summary panel also displays the patient history documented by the intake staff on the Histories template. You can add diagnostic studies with a documented Result or Interpretation to the grid in the Reason for Visit panel by selecting the Add to HPI Grid button. The grid includes a list of categories on the left pane to select and view the documented data. You can filter the patient history records by selecting the Medical History or Surgical History option for Past Medical/Surgical. You can view and enter confidential details provided by the patient during the course of the encounter using The Confidential link. You can select History Review to open the History Review template and select the applicable option to

NextGen® Adaptive Content Engine Help Enterprise 8

Patient's Social History

You can document a patient's social history. You can open the individual social history template or the Adult Social History template to document the social history information of a patient. The Adult Social History template includes the existing social history templates arranged in a one-page panel format. Each panel includes the data fields from the respective social history template. You can choose to document the social history information of the patient on individual social history templates or on the Adult Social History template. You can document the following social information for an adult patient on the social history templates or the Adult Social History template: Tobacco/Vaping Use Alcohol/Caffeine Statuses Lifestyle Occupation Comment Diet History Environmental Note: NextGen® Adaptive Content Engine is packaged with the individual social history templates as the default social history templates. However, the practice can configure the Practice Configuration template to set

Histories Template

Recommendations

Documenting Social Details of Pediatric Patients

Dental

Histories Template

Add Social History

Documenting the Patient History Summary

Patient's Social History

Documenting Social Details of Pediatric Patients

Dental

Histories Template

Add Social History

Documenting the Patient History Summary

Patient's Social History