Record Asthma History of Present Illness

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Asthma Flowsheet

You can document the diagnosis and clinical assessment for a patient on the Asthma Flowsheet template. You can use the Asthma-HPI template to document the details on Asthma Flowsheet. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. On Top Toolbar, select Templates . The Select Template window opens. Open the SOAP template, and expand the Reason for Visit panel. The Asthma HPI template opens. Select Asthma Flowsheet. The Asthma Flowsheet template opens. Asthma Flowsheet To add a diagnosis, do the following: Select the Asthma Diagnosis field. The Diagnosis Search window opens and displays the asthma diagnoses. Diagnosis Search Window Select an asthma diagnosis from the list. In the Status field, select a status from the list. In the Clinical Assessment section, select Upload Vital Signs to fill the fields with previously recorded vital signs or enter the values manually as follows: For Height, enter a value in the in or cm field within the range of 12 t

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Patient's Reason for Visit as a Provider

The reason for visit added by the intake staff on the Intake template appears on the SOAP template. The Introduction field is an editable field that displays a brief summary of the patient's reason for visit. Open NextGen® Enterprise EHR. On the SOAP template, in the Reason for Visit panel, do one of the following: Select one of the reasons for visit entered previously. Select a complaint from the reasons for visits in the left pane. The associated HPI template opens. Note: If you select reason(s) for visit using the Additional / Manage link, then the reasons appear in the Chief Complaint column in the data grid. You must select the reasons listed in the Chief Complaint column in the data grid to open the associated HPI template. Reason for Visit panel On the associated HPI template, enter the appropriate data. Enter any comments. Select Save & Close. The entered details appear in the History of Present Illness column in the Reason for Visit panel. Parent topic: SOAP Template

NextGen® Adaptive Content Engine Help Enterprise 8

Document Reasons for Visit

You can document the reasons for the visit of a patient in the Reason for Visit panel. Open NextGen® Enterprise EHR. Open the Intake – Cardiology template. Click the Reason for Visit panel. To add a Reason for Visit, do one of the following. To enter the reason for the visit and do not want to enter the history of present illness, select the Do not launch HPI check box. From the left pane, select a reason for visit. Click the Other list, select a reason for a visit from the list, and then click OK to get the corresponding window to fill in the information. The reason for the visit is added. To enter additional information for the provider to review, click the Intake Comments link, and type your comments. When you enter additional information, the Intake Comments link appears purple on both the Intake and SOAP tabs. For each symptom, do the following. If a symptom is not present, select the Absent check box. The grid displays a statement of negative findings in the History of Present Il

NextGen® Adaptive Content Engine Help Enterprise 8

Review Reasons for a Patient's Visit

You can review and update reasons for a patient's visit during the provider workflow. Open NextGen® Enterprise EHR. Open the SOAP, and then expand the Reason for Visit panel. Review and update the patient summary in the Introduction field. Review and update reasons for visit, diagnostic studies, and chronic conditions. To add any additional information, select Comments. Review Intake Comments on the SOAP Template Review comments entered during the intake if the Intake Comments link on the SOAP template indicates that content is present. Edit a Reason for Visit on SOAP You can edit existing reasons for visits on the SOAP template. Add and Review Comments for the History of Present Illness You can review and enter additional comments for a patient's history of present illness (HPI). Remove a Studies Reviewed on SOAP You can remove the historical diagnostic studies that are added to the history of patient illness in the Studies Reviewed section on the SOAP template. Document Depression Sy

NextGen® Adaptive Content Engine Help Enterprise 8

Document with the Laterality View

Open the Intake template and enter a Specialty and Visit Type.Enter Physical Therapy for the Specialty and Physical therapy evaluation for the Visit Type. In the Reason for Visit panel on the Objective tab, do one of the following to open the corresponding HPI template: If no Reason for Visit was entered during the intake process, select a reason for visit value (for example, elbow) . If a Reason for Visit appears in the grid, click the desired row. In other specialties, the Reason for Visit panel is also available on the SOAP tab. At the top of the dynamic HPI template, a ribbon field appears with any other documented reasons. To change the Reason on the dynamic HPI template, do one of the following: Click the blue arrow next to the Reason field to select a value from the list. In the top ribbon, click the arrow to toggle and select a previously documented reason and move that value to the Reason field. Click intro in the left pane. Each reason includes an intro. The options available

NextGen® Adaptive Content Engine Help Enterprise 8

Reason for Visit on the SOAP Template

Open the SOAP template. Do one of the following: If the Introduction field contains text, review the content and make any necessary changes. If the Introduction field is blank, compose an introduction for the patient. The introduction appears as the first sentence of the visit note, and it can be edited for the individual patient. A typical introduction might contain the patient's age, gender, and the reason for visit. If checked, clear the Do not Launch HPI check box. To add additional details to a previously entered reason for visit, click one of the reasons for visit in the data grid. The appropriate HPI template opens. To add a new reason for visit: Select a complaint from the reasons for visit in the left pane. In the Other field select a reason from the resulting list or type a reason for visit. The associated HPI template opens. On the HPI template, enter the appropriate data. Enter any comments. Click Save & Close. The History of Present Illness column in the Reason for Visit p

Record Asthma History of Present Illness

Recommendations

Document the Asthma Flowsheet

Document the Patient's Reason for Visit as a Provider

Document Reasons for Visit

Review Reasons for a Patient's Visit

Document with the Laterality View

Reason for Visit on the SOAP Template

Document the Asthma Flowsheet

Document the Patient's Reason for Visit as a Provider

Document Reasons for Visit

Review Reasons for a Patient's Visit

Document with the Laterality View

Reason for Visit on the SOAP Template