Diagnosing Patient Problem

NextGen® Enterprise EHR Help

Problems Module

The Problems module enables you to list and maintain specific medical problems and diagnosis information related to each patient. When you use the Problems module to add medical problems to the patient's medical record, they are categorized as either active or resolved. All of the problems added to a patient's medical record appear under the Encounter History tab. From the Problems module, you can: Set a specific date for the onset of a problem. Provide a description and fully specified name of a problem. Assign a concept ID and a billing code. Indicate whether a problem is chronic. Specify when, how, and by whom a problem was resolved. Search for all providers within the enterprise to assign the responsible provider. The Problems module has two tabs, the Problem List tab and the Billing ICD List tab. Each tab has a data display area and a data entry area, and each tab has its own features and functions for both areas. Note: If the instructions reference problems and you are using the

NextGen® Enterprise EHR Help

Opening the Imaging Module

Before you begin Open the Imaging module by doing one of the following: Open an image saved to a patient's medical chart Open a new image stored on your system Scanning a new image When you open the Imaging module, it adds the following items to the Main menu: Items to the View menu. Imaging menu item. Add an Existing Image to the Patient Chart You can add an image to the patient chart. Add a Web Camera Image to the Patient Chart You can add a web camera image to the patient chart. Scan an Image to Add to the Patient Chart You can scan an image to add it to the patient chart. Save an Image to an Encounter You can save an image to the patinet chart or encounter. Open an Image from the Patient Chart You can open an image in the Encounter History or Categories tab. Guidelines for Working with Multi-Page Images Open PDFs You can access the PDFs in the Images module. Parent topic: Imaging Module

NextGen® Enterprise EHR Help

Problem List

The Problem List tab enables you to view the details of the active, inactive, resolved, and unresolved problems of a patient and update them as needed. You can record and update a patient’s problems using the Systemized Nomenclature of Medicine - Clinical Terms (SNOMED-CT®) concept. SNOMED-CT® is a standard vocabulary used to express clinical terms. SNOMED-CT® is comprised of descriptive terms or synonyms related to a clinical concept and provides links between different concepts. The problem list is demographic and is not associated with an encounter. After you record a problem if you need to use it as a diagnosis for billing, you must add the problem to the billing ICD list. Problem List View and modify the details of problems in the problem list. Problem List Data Entry Area The problem list data entry area displays options for managing patient problems. Managing Problems and ICD Codes Parent topic: Diagnosing Patient Problem

NextGen® Enterprise EHR Help

Open Billing ICD List

The Billing ICD List tab of the Problems module displays the details of the billing ICD codes of a patient. Open NextGen® Enterprise EHR, and select a patient from Patient Lookup window. Select an existing encounter from the Encounter History or create an encounter. To open the Problems module, select Problems on the Quick Buttons panel.The Problems module opens displaying the Problem List tab by default. To open the billing ICD list, select the Billing ICD List tab. Billing ICD List Billing ICD List The billing ICD list displays all the resolved and unresolved billing ICD entries of a patient. Add an ICD to the ICD Billing List You can add an entry to the Billing ICD List using the add ICD feature. Modify an ICD in the ICD Billing List Modify the entries in the Billing ICD List to update the information displayed in the Billing ICD List Display Area. Specify a Diagnosis Status Set the diagnosis status to Resolved in the Billing ICD List tab. Delete an ICD Code from the ICD Billing Lis

NextGen® Enterprise EHR Help

Managing Problems and ICD Codes

The Problem List and the Billing ICD List enable you to add, modify, resolve, and delete patient diagnosis, problem information, and Billing ICD entries. Add a Problem to a Patient Chart You can add a problem to the patient chart that can later be modified or updated. Viewing or Adding Synonyms in the Problem List Modify a Problem in the Problem List You can update the patient's problem for an unlocked encounter. Duplicate a Problem You can recur patient's problem for an unlocked encounter. Categorize a Problem Delete a Problem in the Problem List You can delete a problem from the patient's Problem List if it is entered by mistake or no longer relevant. View Who Changed a Problem Parent topic: Problem List

NextGen® Enterprise EHR Help

Add an ICD to the ICD Billing List

The Add ICD option enables you to add a ICD code to the billing ICD list. Open Billing ICD List. On the Billing ICD List tab, select the Add ICD button. The Add Billing ICD window opens. All Diagnosis To search for a patient's diagnosis, do the following In the Search field, enter the diagnosis description in full or in part. Specify whether you want the Add Billing ICD window to search for ICD codes in the All Diagnoses list (default), the Patient's Diagnoses list, the Patient's Chronic Diagnoses list, a Favorites folder, or by Categories. Select Search. The application displays a list of search results. The most frequently assigned ICD code appears at the top of the list. Search results To add a search result to a favorite's list, right-click the search result and select Add to Favorite Group. To add a synonym to the search result, right-click the search result and select View/Add Synonyms. To add the diagnosis to the patient's chart, select the diagnosis and select Select. The appli

Diagnosing Patient Problem

Recommendations

Problems Module

Opening the Imaging Module

Problem List

Open Billing ICD List

Managing Problems and ICD Codes

Add an ICD to the ICD Billing List

Diagnosing Patient Problem

Problems Module

Opening the Imaging Module

Problem List

Open Billing ICD List

Managing Problems and ICD Codes

Add an ICD to the ICD Billing List