Managing Problems and ICD Codes

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

View Who Changed a Problem

Each time someone creates or modifies a problem, the application records who made the change and when it was done. You can view who created and last modified any problem in the Problem List or the Billing ICD List. Do one of the following: Select a problem in the Problem List data entry area. Select a Billing ICD Code in the Billing ICD List data entry area. Right-click the problem or Billing ICD code, and then select Who/When. The Modification Information window displays the name of the person who entered the problem or diagnosis into the patient chart (Creator and Creation Date & Time fields), and the name of the person who last modified the selected Problem or Billing ICD Code. Modification Information Parent topic: Managing Problems and ICD Codes

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

Viewing or Adding Synonyms in the Problem List

The View/Add Synonym function enables you to supplement the default system synonyms with a user-defined list of terms that display when you search for a problem. The View/Add Synonym function is available in both the Problem List tab and the Billing ICD List tab. In the Problem List, synonyms are added to the list of terms that display for the SNOMED® Concept when the Fully Specified Name is entered in the search field. In the Billing ICD List, synonyms are added to the list of terms that display when an ICD Code is entered in the search field. Adding synonyms to the SNOMED® Concept and the Billing ICD List simplifies searching for terms and helps to ensure a standard list of customized search results when variations of a term are entered in the search field. Open View/Add Synonyms Window in the Problems List Open View/Add Synonyms Window in the Billing ICD List Parent topic: Managing Problems and ICD Codes

NextGen® Enterprise EHR Help

Delete a Problem in the Problem List

Open the Problems Module. Select the patient's encounter that contains the problem you want to delete. Note: You can delete a problem from a patient's problem list if the problem is not assigned to a locked encounter. Select the problem in the problem list. Do one of the following: Right-click the problem, and then select Delete. On the problem list data entry area toolbar, select Delete. The Delete Problem message prompts you to confirm if you want to delete the problem. Select Yes to delete the problem. If the problem was not entered in error, clear the Entered in error check box. Select Refresh in the problem list toolbar to view the updated problem list. Note: All deleted problem list entries are displayed in the Deleted Items window. To view deleted problems, from the problem list toolbar, select Deleted Items. Parent topic: Managing Problems and ICD Codes See also Open the Problems Module

NextGen® Enterprise EHR Help

Manage Billing ICD List Entries

You can mark a Billing ICD entry as chronic, see who last modified the entry, resolve a problem, or delete an entry. Open Billing ICD List. In the Billing ICD List Data display area, right-click a Billing ICD entry. A menu of functions and features opens. Billing ICD List To mark a Billing ICD entry as chronic, right-click the Billing ICD entry and select Set Chronic. The Set Chronic button is only active if the selected Billing ICD entry has not been set as chronic. Setting a problem as chronic in the Billing ICD List does not set that same problem to Chronic in the Problem List. To see who last modified the entry and when, select Who/When. The application displays the Modification Information window. Modification Information To refresh the changes for the Billing ICD entry, select Refresh. To add a problem, select Add Problem. To mark a problem as Resolved, select Resolve. To create a copy of an existing ICD Code, right-click the code and select Recur. To delete a problem, select Del

Managing Problems and ICD Codes

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Managing Problems and ICD Codes

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Managing Problems and ICD Codes

Managing Problems and ICD Codes

View Who Changed a Problem

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Viewing or Adding Synonyms in the Problem List

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Manage Billing ICD List Entries