Problems Module

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

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

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

Open the Problems Module

Open NextGen® Enterprise EHR, and select a patient from Patient Lookup window. Select an encounter from the Encounter History tab 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. Problem List Parent topic: Problems Module

NextGen® Enterprise EHR Help

Add a Problem to a Patient Chart

Open the Problems Module. On the Problem List tab, select Add Problem. The Problem Search window opens. To search for the patient's problem, do the following: In the search field, enter the problem description in full or in parts. Select Search. The problem search results appear. Problem search results Select a problem, and then select Select to add the problem to the patient's encounter. Close the Problem Search window. The selected problem is added to the Unresolved group in the problem list. Note: By default, the Problem Status of the new problem is set to Active. Note: For a new problem created from a template trigger, the Problem Status is set to Active and Verification Status is set to Confirmed by default. Modify the problem list data entry fields. To add the problem to patient's record, select Save. Modify the Problem List Data Entry Fields Indicate that a Patient Has No Active Problems You can view the patient chart which has no active problems for the selected patient. Parent

NextGen® Enterprise EHR Help

Categorize a Problem

You can categorize a patient's problems as Resolved, Inactive, or Unresolved. Each newly added problem is automatically listed as Active. Select the patient's encounter to specify a status. Open Problems module. Select the problem in the Problem List data entry area. Note: If there is more than one instance of a Problem, select the top level displayed for the Problem to resolve all of the listed instances or select a specific Onset Date of the problem to resolve the particular instance. If you are resolving multiple instances of the same Problem, a warning message displays. Select the Yes button. Select the Problem Status list in the Problem List data entry area and select Active, Inactive, or Resolved. If you are setting the status to Resolved, enter a resolved date by using the Resolved Date calendar. Select the Accept button. If you try to close the Problem module without saving your changes, a message prompts you to save or cancel the changes. NextGen® Enterprise EHR automatically

Problems Module

Recommendations

Open Billing ICD List

Problem List

Diagnosing Patient Problem

Open the Problems Module

Add a Problem to a Patient Chart

Categorize a Problem

Open Billing ICD List

Problem List

Diagnosing Patient Problem

Open the Problems Module

Add a Problem to a Patient Chart

Categorize a Problem