SOAP Template

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

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

Overview of the Provider Workflow

You can review the patient's medical summary details on the Home Page template and then proceed to the SOAP and Finalize templates. The provider workflow includes the following: Reviewing and updating the data documented by the intake staff during the patient encounter and providing any additional information. Documenting the problems and various physical examination findings. Documenting the performed procedures. Documenting the treatment plan. Documenting Evaluation and Management (E&M) codes. For more information on the SOAP and Finalize templates, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide forNextGen®Adaptive Content Engine. Patient Tracking in the Provider Workflow You can update the patient tracking details using the Patient Tracking on the Patient Information Card (PIC). Review of Intake Details by Provider You can start the visit by reviewing the patient's details entered by the intake staff on the Home Page template, to deter

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

Generate Notes Associated with Encounters

You can generate the notes associated with an encounter on the SOAP template. Open NextGen® Enterprise EHR. Open the SOAP template. Select . Select the required note in the list. Select OK. Parent topic: Review of SOAP Details by Provider Parent topic: Cardiology Provider Workflow Parent topic: Overview of the Provider Workflow Parent topic: The Provider Workflow Parent topic: SOAP Template

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

SOAP Template

Recommendations

Review of SOAP Details by Provider

The SOAP Template

Overview of the Provider Workflow

SOAP Template

Generate Notes Associated with Encounters

Reviewing Patient's General Information on SOAP

SOAP Template

Review of SOAP Details by Provider

The SOAP Template

Overview of the Provider Workflow

SOAP Template

Generate Notes Associated with Encounters

Reviewing Patient's General Information on SOAP