Problem List

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

Diagnosing Patient Problem

You can list and maintain specific medical problems and diagnosis information related to each patient. Medical problems are categorized as either active or resolved. All of the problems added to a patient's medical record appear under the Encounter History tab. The Imaging module enables you to use clinical images while working with a patient's medical record. Each image is cataloged by patient, date, and title. The Imaging module consists of the main window that displays the images, the Imaging toolbars, and the Imaging status bar. An image must be saved to the patient's chart before the Imaging module opens and the toolbars are displayed. Problems Module Overview of the Problems Module. Problem List The Problems List tab displays details of the problems of a patient. Open Billing ICD List Open the billing ICD list to view and edit the billing ICD codes of a patient. Related concepts Problem List Problem List Data Entry Area Managing Problems and ICD Codes Working with Images Electron

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® Adaptive Content Engine Help Enterprise 8

Add a New Problem to a Patient's Problem List

Before you begin Ensure that you have selected the Specialty and Visit Type as Care Management. On the Care Transitions tab, expand the Problem List after Discharge panel, and then click Add. The Problems window opens. Click Add Problem. A search window appears. Add Problem Window Note: Problems are stored in the database and displayed using SNOMED® CT (SNOMED Clinical Terms). Search for the problem by typing a full or partial name of the problem in the search box. Note: The Add to My Tracked Problems option is selected as a default. Click the desired problem. Click Select to display and add any additional details. Make any necessary changes to the problem. Click Accept to add the problem to the list. The following options are also available: Options List Re-Code: to change or edit the problem code. Resolve: to set resolve date for the problem. Set Chronic: to add the problem to the patient’s chronic problems. Delete: to remove the problem. Resources: available information about the pr

NextGen® Adaptive Content Engine Help Enterprise 8

Patient's Problem List

You can manage a patient's problems. You can perform the following actions in the Problem List panel. Record, modify, and retrieve a patient's clinical problem list electronically to meet Quality Reporting requirements Document the patient's chronic conditions and ongoing clinical problems View problems from past encounters Add problem details Problem List You can also indicate if a patient's documented problem is completed and reviewed, and if there is any active problems. You can select the Include Resolved check box to include the resolved problems. Open Problem List You can access the problem list to document and view a patient's problem history. Add Problems in the Problem List You can add a problem to the problem list of a patient. Update a Problem You can modify a documented problem. Sort the Problem List You can sort the problem list details. Documenting Problem Notes You can document a problem note for a patient problem. Parent topic: Overview of the Histories Template Parent

NextGen® Adaptive Content Engine Help Enterprise 8

Select an Assessment from Clinical Problems

On the Add or Update Assessment template, Clinical Problems section, filter the grid by selecting Show chronic, Show my tracked problems, or No active problems. Assessments Select a Clinical Problem item from the grid. A system check determines if there was a previously mapped ICD code for that clinical problem for the open patient chart. If there is a previously saved mapping, that ICD code is added to the ICD description and ICD Code fields to be used for today’s assessment. The Clinical Problems section includes the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED - CT®) problem list (from the Concept Id column on the Problem List tab in the Problems module). The system translates the selected diagnosis into a SNOMED® code and saves it in the Clinical Problems section. Note: The SNOMED list contains healthcare concepts with unique meanings and formal, logic-based definitions organized into hierarchies. The list provides the ability to consistently index, store, and ret

Problem List

Recommendations

Problems Module

Diagnosing Patient Problem

Managing Problems and ICD Codes

Add a New Problem to a Patient's Problem List

Patient's Problem List

Select an Assessment from Clinical Problems

Problems Module

Diagnosing Patient Problem

Managing Problems and ICD Codes

Add a New Problem to a Patient's Problem List

Patient's Problem List

Select an Assessment from Clinical Problems