Patient's Medical History

NextGen® Adaptive Content Engine Help Enterprise 8

Patient's Medical History

The Medical/Surgical/Interim panel enables you to document the medical or surgical history of the patient. If no medical or surgical history exists, you can select the No relevant past medical/surgical history check box. You can filter the past history records by selecting the required check boxes. By default, the Show All check box is selected. Medical/Surgical/Interim panel On the Past Medical History template, the medical conditions and the surgical procedures associated with the current specialty appear alongside a check box in the respective panels. The Medical and Surgical panels include individual and grouped conditions or procedures. The individual conditions or procedures includes only a check box. The grouped conditions or procedure include [+] sign adjacent to the condition which indicates that the condition, or procedure includes sub-items. The conditions or surgical procedures, or sub-items with an asterisk (*) indicate that the condition or procedure, or sub-item is not a

NextGen® Ophthalmic Suite Help 2022.2

Document the Interim History

Open the Histories template. In the Medical/Surgical/Interim panel, select Interim History.The Interim History window opens. Interim History Select an encounter type. If an encounter type does not appear in the list, you can manually enter it. Select the Problem field.If problems are added during previous encounters, the Patient Problems template opens. If there are no problems from previous encounters, then a search window opens. Do one of the following: From the patient problems list, select an existing problem. From the search window, search for and select a new problem and then select the Add to Problem List button. Note: If you manually enter the problem, the Add to Problem List button is disabled. In the Management field, enter the therapy or procedure performed on the patient. Select the current date and then the provider who performed the therapy or procedure. If a provider does not appear in the list, you can manually enter their name. Enter admission details, discharge detail

NextGen® Ophthalmic Suite Help 2022.2

Manage Patient's Disease

You can manage the patient's disease in the Medical/Surgical/Interim panel on the Histories template. Open NextGen® Enterprise EHR. Open the Histories template and select the Medical/Surgical/Interim panel. 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. Past Medical History 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. 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 th

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Medical/Surgical/Interim Panel

You can filter the past history records in the grid by selecting the Medical History/Surgical History/Interim History check boxes. By default, Show All check box is selected. Open the Histories tab. Open the Medical/Surgical/Interim panel. Select Add to open the Past Medical History template. Select the check box corresponding to the correct entry. Note: Items in blue are categories rather than individual selections. Selecting the blue name, or selecting the check box opens a list of choices. The Add Pregnancy Detail button in the Medical panel opens the Pregnancy Outcomes template. Select the Add to Grid button. Past Medical History Expand Surgical to enter past procedures/operations. Surgical panel on the Past Medical History template Select Save & Close. A new past medical history record displays in the panel on the Histories template. Note: If information is entered in the Medical/Surgical/Interim grid during prior visits or by other specialties, that information also displays. Doc

NextGen® Adaptive Content Engine Help Enterprise 8

Patient's Family History

You can document the family history of the patient in the Family panel on the Histories template. The Quality button appears on the Family panel and the Family Health History template which enables you to open the First degree relative information template. The No relevant family history check box indicates that the patient has reported no family medical history in the current (today’s) encounter. The Adopted - no family history known check box indicates if the patient is adopted and medical history details of the biological family are unknown. Family Health History - Family Panel You can use Add to open the Family Health History template. Family Health History The available conditions for the specialty appear alongside a check box in the Family Health History template. The template enables you to document individual medical conditions and grouped medical conditions of patient's family. You can identify the conditions as follows: The individual conditions includes only a check box. The

NextGen® Ophthalmic Suite Help 2022.2

Individual and Grouped Conditions and Procedures

Conditions of interest to a specialty appear on the Medical panel of the Past Medical History template and on the Family Health History template. Both templates enable you to document the patient's medical conditions and their family members medical history. Individual Conditions- Conditions listed without a plus sign [+] to the left of the item represent a single general disease or disorder. Grouped Conditions- Conditions listed with a plus sign [+] are types or groups that represent a category of diseases or disorders, with more than one associated disease or disorder as items to select from. On the Surgical panel of the Past Medical History template, surgery types or groups are similarly organized and identified with a [+], and items listed without a [+] are single surgical procedures. Note: Conditions or surgical procedures with an asterisk (*), indicate that the condition or procedure does not have a SNOMED code. The Configure Medical Surgical and Family History system template is

Patient's Medical History

Recommendations

Patient's Medical History

Document the Interim History

Manage Patient's Disease

Document the Medical/Surgical/Interim Panel

Patient's Family History

Individual and Grouped Conditions and Procedures

Patient's Medical History

Document the Interim History

Manage Patient's Disease

Document the Medical/Surgical/Interim Panel

Patient's Family History

Individual and Grouped Conditions and Procedures