Record a Discharge Diagnosis

NextGen® Adaptive Content Engine Help Enterprise 8

Document General Transition of Care Information for a Patient

Before you begin Ensure that you have selected the Specialty and Visit Type as Care Management. Click the Care Transitions tab.The Cm Care Transitions template opens. Cm Care Transitions Click the PCP field.The field populates with the Primary Care Practitioner established in the patient's demographics. If there is no PCP selected in the patient chart, the Modify Patient Information template opens, enabling you to select a PCP. Do one of the following: Click the Encounter Type field to launch a list of transitional care encounter types and then select an encounter type from that list. Click the blue arrow to the right of the Encounter type field to launch the interim history data list and then select a past encounter from the interim history data. Click the first Historian field and select the relationship of the historian to the patient from the resulting list. If needed, click the second Historian field and select the relationship of the second historian to the patient from the resul

NextGen® Adaptive Content Engine Help Enterprise 8

Care Transitions Panels

The Care Transitions tab consists of: Panel Description General Use this panel to enter a patient’s general care transition information, including the primary care physician, case manager, and the facility admitted to or discharged from. Discharge Diagnosis Enables you to enter a diagnosis for a patient that can be used for continuity of care if the patient is being transitioned to another provider. The Discharge Diagnosis panel documents the diagnoses information after the patient is discharged from the hospital/facility. Problem List after Discharge The Problem List after Discharge panel allows an update of the patient’s problem list, based on the discharge information received. Parent topic: Care Transitions Tab

NextGen® Adaptive Content Engine Help Enterprise 8

Update a Patient's Problem List

Before you begin Ensure that you have selected the Specialty and Visit Type as Care Management. On the Care Transitions tab, and expand the Problem List after Discharge panel. Select the appropriate checkbox to build the description of services required for the patient. If required, type additional text into the description. If the patient currently does not have any active problems, click the No active problems option. To add a new problem to the list, click Add. The Problem module appears. Note: For information on using the Problem module, go to the NextGen Healthcare Success Community and download the latest version of the Problems Module User Guide for NextGen® Enterprise EHR. Show chronic and Show my tracked problem options filter the patient’s problem list. Parent topic: Care Transitions Tab

NextGen® Adaptive Content Engine Help Enterprise 8

Add a New Problem to a Patient's Problem List

Before you begin Ensure that you have selected the Specialty and Visit Type as Care Management. On the Care Transitions tab, expand the Problem List after Discharge panel, and then click Add. The Problems window opens. Click Add Problem. A search window appears. Add Problem Window Note: Problems are stored in the database and displayed using SNOMED® CT (SNOMED Clinical Terms). Search for the problem by typing a full or partial name of the problem in the search box. Note: The Add to My Tracked Problems option is selected as a default. Click the desired problem. Click Select to display and add any additional details. Make any necessary changes to the problem. Click Accept to add the problem to the list. The following options are also available: Options List Re-Code: to change or edit the problem code. Resolve: to set resolve date for the problem. Set Chronic: to add the problem to the patient’s chronic problems. Delete: to remove the problem. Resources: available information about the pr

NextGen® Adaptive Content Engine Help Enterprise 8

Care Transitions Tab

You can document information and instructions for a patient's transitions of care using the Care Transitions tab. Cm Care Transitions Care Transitions Panels Document General Transition of Care Information for a Patient Record a Discharge Diagnosis Update a Patient's Problem List Add a New Problem to a Patient's Problem List Parent topic: Care Management

NextGen® Adaptive Content Engine Help Enterprise 8

Record Recent Patient Hospitalizations

Before you begin Ensure that you have selected the Specialty and Visit Type as Care Management. On the Comp Assessment tab, expand Recent Hospitalizations panel. Click the Location field and select the hospital the patient was admitted to from the resulting list. Click the Admit date field and select the date the patient was admitted to the hospital from the resulting calendar. Click the D/C dates field and select the date the patient was discharged from the hospital from the resulting calendar. Click the D/C diagnosis field, and then select a discharge diagnosis from the window that appears. Click the appropriate option for Summary report received. Click Add. The record appears in the Recent Hospitalizations. Repeat this procedure to add additional hospitalizations. Remove Patient Hospitalization Records Parent topic: Comp Assessment Tab

Record a Discharge Diagnosis

Before you begin

Recommendations

Document General Transition of Care Information for a Patient

Care Transitions Panels

Update a Patient's Problem List

Add a New Problem to a Patient's Problem List

Care Transitions Tab

Record Recent Patient Hospitalizations

Document General Transition of Care Information for a Patient

Care Transitions Panels

Update a Patient's Problem List

Add a New Problem to a Patient's Problem List

Care Transitions Tab

Record Recent Patient Hospitalizations