Reviewing Patient History on SOAP

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

Review of Vital Signs on SOAP

You can review and update a patient's vitals signs documented by the intake staff, in the Vital Signs panel on the SOAP template. You can add multiple vital signs for a patient during an encounter. The Vital Signs panel displays the most recent value for each vital sign. Vital Signs The Add button opens the age specific vital signs template based on the patient age and the Pediatric Age configuration on the Practice Configuration template. For more information on the Pediatric Age setting, go to NextGen Healthcare Success Community, and download the latest Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. Add Vital Signs on SOAP While examining a patient, you can add the patient's vital signs in the Vital Signs panel on the SOAP template. Edit Vital Signs You can edit the vital signs details entered during the intake process, in the Vital Signs panel on the SOAP template. Parent topic: Review of SOAP Details by Provider Parent topic: The Provider Workflow P

NextGen® Adaptive Content Engine Help Enterprise 8

Reviewing Patient's General Information on SOAP

You can view the general details of a patient in the General panel on the SOAP template. In the General panel, you can do the following: Document the relationship of the person who provides the patient information, in the Historian field. Capture the electronic Summary of Care requests and receipts that are completed electronically, and provide the information as reportable fields on the Transitioning Into Care template. On the Addition Visit Information template, you can provide answers for the preconfigured questions in the Interpreter Details category. You must document interpreter details when someone else interprets the patient’s communication for you. Indicate if the patient for the current encounter is new or established. General panel Parent topic: Review of SOAP Details by Provider Parent topic: Overview of the Provider Workflow

NextGen® Adaptive Content Engine Help Enterprise 8

SOAP Template

You can review and modify the documented patient intake and histories information on the SOAP template. You can review the Asthma Flowsheet, Allergy Test Flowsheet, Spirometry, and Nebulizer panels. You also can document physical exam, assessment plan, and communication details. SOAP Link Icons The icons for various links appear on the SOAP template. 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. Patient's History Summary Documentation by Provider You can document a patient's past medical or surgical history, interim, social, family, and diagnostic study history in the History Summary panel. Document Vital Signs The provider reviews the vital signs added by the Intake staff on the Intake template and makes the applicable changes. Patient's Physical Exam You can examine a patient and document the associated information using the Physical Exam panel that displays a list of exam cate

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

Reviewing Patient History on SOAP

Recommendations

Review Reasons for a Patient's Visit

Review of Vital Signs on SOAP

Reviewing Patient's General Information on SOAP

SOAP Template

Review of SOAP Details by Provider

SOAP Template

Review Reasons for a Patient's Visit

Review of Vital Signs on SOAP

Reviewing Patient's General Information on SOAP

SOAP Template

Review of SOAP Details by Provider

SOAP Template