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Constitutional
In the
Constitutional
section:
Select the
Normal
or
Abnormal
option to document the patient’s
Mood/affect
.
Select
Oriented x3
or
Abnormal
option to document the patient’s
Orientation
.
Constitutional
NextGen® Medication Inventory Control Help 10.6.3.0
Post Procedure Information
Use the Post Procedure section to capture post procedure information such as complications, hand movement (HM) vision, vision improvement, and if the central retinal artery is examined and open. Check the appropriate check boxes to document post procedure information. Parent topic: Constitutional, Preop/Postop IOP & Post Procedure
NextGen® Medication Inventory Control Help 10.6.3.0
Pre & Post Intraocular Pressure
Use the Preop IOP and Postop IOP section to document pre-procedure and post-procedure intraocular pressure. Select the OD and/or OS field(s) and select a value from the picklist. Parent topic: Constitutional, Preop/Postop IOP & Post Procedure
NextGen® Medication Inventory Control Help 10.6.3.0
Constitutional, Preop/Postop IOP & Post Procedure
Use the sections below the template panels and Injection History grid to document the patient’s mood/affect and orientation, pre-operative and post-operative intraocular pressure, and post procedure observations. Constitutional Pre & Post Intraocular Pressure Post Procedure Information Parent topic: Documenting Ophthalmology Injections
NextGen® Orthopedic Suite Help 80.2.14.0
Document Patient History for Post-Operative Visits
You can document a patient's history such as details of the last injection, pain, medications, and allergies for a post-operative visit. On the Non Billable Visit template, expand the History panel. Enter the details of the last injection in the following order: Click the Last Inj field, select the last injection date, and then click OK. Enter the duration of the relief in hours, days, weeks, and months. Enter the details of pain as follows: Indicate the severity of the pain. Click the Pain Scale field, and select the pain scale from one to ten from the list. Click the Status % field, select the percentage of the pain status, and then click OK. Select one of the following to indicate the pain status. B. Better S. Same W. Worse In the Ambulatory Aids/Braces, Assoc Symp, and Function/Activity Level sections, do the following: Click the blank field, select the appropriate condition from the window, and then click OK. Indicate the applicability of the selected condition. Note: You can ente
NextGen® Adaptive Content Engine Help Enterprise 8
Document the Pre-Procedure Care Details of Contraceptive Implant
You can document the pre-procedure care details of contraceptive implant in the Pre-Procedure Care section on the Contraceptive Implant Procedure template. Open the Contraceptive Implant Procedure template. In the Pre-Procedure Care section, select LMP. If LMP is entered on the Vital Signs template, LMP appears automatically in the LMP field. Optional: Select the Postpartum check box. Enter the pre-op contraception details. Optional: Select the following check boxes as applicable. Consent was obtained Procedure/risks were explained Questions were answered Correct patient is identified Correct side and site confirmed Negative pregnancy test History reviewed and no contraindications To document the patient's consent details, select the Consent link and document the details in the Consent - Procedure template. Parent topic: Open the Subdermal Contraceptive Implant Related tasks Open the Subdermal Contraceptive Implant
NextGen® Adaptive Content Engine Help Enterprise 8
Documenting General Patient information
The Subjective template enables you to document information such as surgical data, authorized visits, reason for visit and history of present illness, vital signs, and comments. Subjective Enter or Review Surgical Data, Authorized Visits, and Diagnosis Encounter Diagnosis Treating Assessments Parent topic: Physical Therapy
