Review of Vital Signs on SOAP

NextGen® Adaptive Content Engine Help Enterprise 8

Reviewing Patient History on SOAP

You can review and edit a patient's medical history in the History panel on the SOAP template. The following categories in the History panel provide the corresponding history details. Past Medical/Surgical Interim Social Family Diagnostic History Panel The Social Determinants of Health and PRAPARE® links appear based on the Practice Configuration practice template settings. For more information on these settings, go to NextGen Healthcare Success Community, and download the latest Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. Review Patient's History Summary on SOAP You can review and update a patient's history summary documented by the intake staff during the previous encounters, in the History panel on the SOAP template. Adding Patient's History Summary on SOAP You can update the history details entered by the intake staff and add any additional history details in the History panel on the SOAP template. Parent topic: Review of SOAP Details by Provider

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

The SOAP Template

You can use SOAP to review the patient information gathered during intake and to document the exam, assessment, and plan. On the SOAP template, you can review the patient's visit type, messages, and risk indicators. You can indicate if the patient is new or established for the current encounter on the header of the SOAP template. You can also review or document the following: General information Reason for visit History summary Review of systems Vital signs Physical exam Assessment and plan Parent topic: Review of SOAP Details by Provider Parent topic: Overview of the Provider Workflow

NextGen® Adaptive Content Engine Help Enterprise 8

Review and Update Pediatric Vital Signs

If you need to update a vital sign of a patient, ensure that you are editing the desired record, as vital signs can be entered multiple times during the encounter. Open the SOAP template. In the Vital Signs panel, select a record in the grid and click Edit. For patients who are two years or younger, the Pediatric Under 2 Years Vital Signs template opens. For patients who are older than two years, the Pediatric Over 2 Years Vital Signs template opens with the values filled in the respective fields. Edit the corresponding vital sign. Click Save, and then Close. View Pediatric Growth Charts You can view the pediatric growth chart based on the age and measurements of the patient. The standard growth chart measures BMI, weight, height, and head circumference. View Pediatric Bone Age History You can view the patient's growth charts individually on the Vs Charts Peds template. Parent topic: Review of SOAP Details by Provider Related tasks Add Vital Signs of Pediatric Patients

NextGen® Adaptive Content Engine Help Enterprise 8

Review of SOAP Details by Provider

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, assessment plans, and provider communications. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan You can select the Record contains substance use disorder information check box on the SOAP template header to include the long or short form of disclosure for Substance Abuse and Mental Health Services Administration (SAMHSA) 42 CFR Part 2 provisions in the generated documents and reports. You can use Quick Notes to save the documented SOAP findings as a default set that can be used in future encounters. For more information on these settings, go to NextGen Healthcare Succes

NextGen® Adaptive Content Engine Help Enterprise 8

SOAP Template

You can review and modify the patient’s reasons for visit, review of systems, and vital signs documented by the intake staff on the SOAP template. You can also review the patient's visit type, alerts, and risk indicators. In addition, you can document the physical examination details, history, and plan information. You can review and modify the following details on the SOAP template. General information Reasons for visit History Review of systems Vital signs Physical examination Assessment and plan Although the you could enter the reason for visit and HPI on the Intake template, there are options available on the SOAP tab that are not available on the Intake tab. Parent topic: The Provider Workflow

Review of Vital Signs on SOAP

Recommendations

Reviewing Patient History on SOAP

Review Reasons for a Patient's Visit

The SOAP Template

Review and Update Pediatric Vital Signs

Review of SOAP Details by Provider

SOAP Template