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

Problems Module

The Problems module allows 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 Encounters 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 is 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 Billing I

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

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

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

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

Diagnosing Patient Problem

Recommendations

Diagnosing Patient Problem

Problems Module

Opening the Imaging Module

Problems Module

Problem List

Managing Problems and ICD Codes

Diagnosing Patient Problem

Diagnosing Patient Problem

Problems Module

Opening the Imaging Module

Problems Module

Problem List

Managing Problems and ICD Codes