You can modify the problem list data entry fields for problems selected in the Problems List tab.
- Open the Problems Module.
- From the problems list, select a problem.
- Verify that the information entered in Concept ID, Description and Fully Specified Name are correct.
- To modify the Onset Date, select the arrow and use the calendar.
- To modify the Resolved Date, select the arrow and use the calendar.
If you select a date in the future, NextGen® Enterprise EHR displays a warning message. Selecting a correct Resolved Date enters the user's ID in the read-only Resolved By field and activates the Resolved Reason field.
- If you have selected a Resolved Date, enter a reason for resolving the problem in the Resolved Reason field.
- From the Problem Status list, select a status.
The available options are:
- Active
- Inactive
- Resolved
- Recurrence
- Relapsed
- Remission
If you select Active or Inactive, the system removes the Resolved Date and any data entered in the Last Addressed (this information is not directly editable), Resolved By, and Resolved Reason fields.
- From the Clinical Status list, select a status.
If the choice is unavailable, contact your System Administrator.
- From the Verification Status list, select a status.
Existing problems have a blank Verification Status that can be manually updated. Changes in Verification Status is tracked in the Encounter History.
If you select Entered in error, the system removes the Clinical Status. Problems with Verification Status as Entered in error are not shown in the Patient Information Card, template grids, or documents.
- To specify whether the problem is chronic, select or clear the Chronic check box.
- To indicate whether the problem is recorded elsewhere, select or clear the Recorded Elsewhere check box.
- Check that the information entered in the Source field is correct.
This information is not directly editable.
- From the Problem Type list, select a problem type.
The
Problem Type list displays a list of SNOMED® problem type codes and their corresponding descriptions. For new patient problems, the default
Problem Type value is
55607006 – Problem (Finding). For historical patient problems and diagnoses, the
Problem Type is blank and can be manually updated.
Note: The Problem Type is a required field for transmitting a CCDA. It is not mandatory to acknowledge the Problem Type field for every new problem added to the patient chart. Default problem type values are populated for newly added problems for NextGen® Enterprise EHR versions 5.9 and higher.
Note: All the external imported codes may not be displayed in the Problem Type list.
The external codes imported through CCDA that are not in the NextGen® Enterprise EHR are displayed in the Problems List Display Area. To enable the columns that display Problem Type data, select Problem Type Description and Problem Type Code in the Preferences button on the data display area toolbar.
- To indicate whether the problem is a secondary condition, select the Secondary Condition check box.
- To indicate whether the problem is a comorbid condition, select the Comorbid Condition check box.
- Select the Responsible Provider ellipsis button.
The
Provider Search window opens.
- In the Provider Search window, enter the search criteria and select Search.
- Select a provider and select OK.
- Select a Provider and Location, if different from the default selection.
- If necessary and appropriate, specify which Side the problem exists (Left, Right, or Bilateral).
- Specify the site in the Site field.
- To save the changes, select Accept.
