Diagnosis Details of Patients

NextGen® Orthopedic Suite Help 80.2.14.0

Medical History of Patients

You can document a patient's medical history such as diseases, disorders, and surgical procedures. The Medical History grid enables you to document and view a patient's diseases and disorders and the surgical procedures performed on them. You can add, edit, and remove the patient's medical histories in this grid. Medical History grid You can select the No relevant past medical/surgical Hx check box if the patient does not have any of the following: Medical history Orthopedic surgical history Surgical history Add Medical History You can add medical history such as diseases, disorders, and surgical procedures of a patient. Parent topic: Patient Intake Details

NextGen® Orthopedic Suite Help 80.2.14.0

Surgical History of Patients

You can document a patient's surgical history and orthopedic surgical history. You can use the following sections on the Intake template to document and view the surgical procedures performed for the patient. Orthopedic Surgical History. You can document and view the orthopedic-specific procedures performed for the patient. Surgical History. You can document and view all other surgical procedures performed for the patient. These sections are shared with several templates of the NextGen® Orthopedic Suite, and the grids in these sections display the date of surgery, global date, side, and description. The grids are sorted by DOS column, and the date of surgery can be entered in the MM/DD/YYYY, MM/YYYY, or YYYY formats. To enter a global date, the date of surgery must be in the MM/DD/YYYY format. Surgical History grids The Orthopedic Surgical History and Surgical History sections display the details from the appropriate templates in the core and NextGen® Orthopedic Suite. Add a Surgical P

NextGen® Orthopedic Suite Help 80.2.14.0

Add the Patient's Diagnoses

You can add a diagnosis to the grid in either of two ways. If you are licensed for Problem Intelligent Medical Objects (IMO) functionality, click the Problem IT button under the grid to launch IMO to add a diagnosis. To use the Inf Common Assessment template, click the Add button under the Diagnosis grid. Select Orthopedic to add an orthopedic-specific diagnosis or the Medical option for all other diagnoses. Click Add under the Diagnosis grid. The Inf Common Assessment template opens. If the template is blank or you want to use a different common assessment, click the Common Assessments field, select a page from the picklist and click OK. Headers and categories are in bold font Items with a plus sign open picklists or code options to choose from Anything with a Description and Code enters directly into the grid. Common Assessment picklist The Inf Common Assessment template displays the corresponding diagnoses. Select one or more diagnoses. The codes you selected appear in the Diagnosis

NextGen® Orthopedic Suite Help 80.2.14.0

Edit a Diagnosis

You can edit the description of a diagnosis. Before you begin Make sure that the applicable template with the Diagnosis grid is open. In the Diagnosis grid, select the diagnosis. Diagnosis grid Click Edit. The IORTS Dx Edit window opens. IORTS Diagnosis Edit window Click the Diagnosis field, and edit the description. Click Update to update the entry and close the window. The updated description appears in the Diagnosis grid. Parent topic: Diagnosis Details of Patients

NextGen® Orthopedic Suite Help 80.2.14.0

Add New Diagnoses from the Common Assessment Template

The Diagnosis grid displays the patient’s diagnoses. The grid defaults to Orthopedic to show Orthopedic-specific diagnoses. The Medical options displays other clinical diagnoses. Click Add under the grid to launch the Common Assessment template. Select a diagnosis to add to the patient’s history. Click Save & Close. Select Diagnoses for Today’s Visit Add Fracture Care Procedure Codes Parent topic: Assessment and Plan for Multiple Fracture Related concepts Diagnosis Details of Patients

NextGen® Orthopedic Suite Help 80.2.14.0

Patient Intake Details

You can document the details of a patient for the provider's reference. You can use the Intake template to view, enter, and update the patient details such as: Chief complaints Vitals Histories Studies Medications Allergies Review of systems Intake template Chief Complaint Pharmacy Intake Comments Patient is Accompanied By Vitals Record NextGen Portal Registration Enter Hand Dominance Electronic Clinical Summary Diagnosis Details of Patients You can view, add, edit, and remove the orthopedic and medical diagnoses of a patient. Medical History of Patients You can document a patient's medical history such as diseases, disorders, and surgical procedures. Surgical History of Patients You can document a patient's surgical history and orthopedic surgical history. Allergies Medications Document Alcohol and Caffeine Use Document Other Social Histories Add Confidential History Document No Tobacco Use, or Unknown Tobacco Use Review of Systems Outside Diagnostics Studies Carbon Copies Intake Sign

Diagnosis Details of Patients

Recommendations

Medical History of Patients

Surgical History of Patients

Add the Patient's Diagnoses

Edit a Diagnosis

Add New Diagnoses from the Common Assessment Template

Patient Intake Details

Medical History of Patients

Surgical History of Patients

Add the Patient's Diagnoses

Edit a Diagnosis

Add New Diagnoses from the Common Assessment Template

Patient Intake Details