Manage Patient's Disease

You can manage the patient's disease in the Medical/Surgical/Interim panel on the Histories template.

1. Open NextGen® Enterprise EHR.
2. Open the Histories template and select the Medical/Surgical/Interim panel.
3. Select Add.
   By default, NextGen® Enterprise EHR fills the Specialty field with the current specialty.

   Note: The Configure Medical Surgical and Family History system template is used to configure the conditions, surgical procedures, sub-items of a condition/procedure, management items, and associated SNOMED codes.
   The Past Medical History template opens.

   

4. To add an item to the Medical or Surgical panel, select the respective check box for the condition or surgery.
   The Onset Date in the Medical panel field or the Date in the Surgical panel field and the Details icon appear beside the selected item.
5. To add problems that are not available on the Past Medical History template, use the Other field.
   • To enter the first appearance date of the condition, use Onset Date in the Medical panel.
   • To enter the performed date of the surgery, use Date in the Surgical panel.
6. Select Onset Date or Date to access the Date Selection window.
   Note: You can enter the Onset date manually into the Onset date field or can select the calendar to select a date.
7. Enter the approximate patient age in the Onset age field.
   Note: You can enter Onset age in days, weeks, months, or years but you cannot enter a future onset age.
8. Select Save & Close.
9. To add an additional description for the condition or surgical procedure, select the Details icon, located beside the selected condition or procedure.
   The Manage Past Medical/Surgical History template opens.

   

10. Select Save to Grid & Close.
    The details of the selected condition or surgery appear in the grid in the Past Medical History Grid panel.
11. On the Past Medical History grid, do one of the following:
    • To clear a condition, surgery details, or entries, select Remove.
    • To return to the Histories template, select OK.
12. To review and update the records in the Medical/Surgical/Interim panel, select the History Review link.
13. To document the patient’s encounters since the last visit, such as an ER visit or hospitalization, select Interim History.