Document an Exam

NextGen® Orthopedic Suite Help 80.2.14.0

Exams

To open an exam, click on its name in the left side navigation pane. Each exam (body area) has its own template. Exams that are most pertinent to the current workflow are shown at the top of the list. You can scroll down to see additional links. Data entered on exam templates is shown in the large grid below the Vitals information on the Physical Exam panel. Each exam template has side navigation to open related templates. For example, shown directly below is the template page that opens when you click the Fracture link. Note that links to other fracture templates are at the top of the left navigation bar. Exam template All exam templates have the QuickPick option to fill in information, as well as the Get Data functionality to pull data forward from previous encounters with the patient. Each physical exam template has an eraser icon for the whole template, and for the specific sections. The eraser icons enable you to erase a portion of the exam or the entire exam. Document an Exam Par

NextGen® Therapy Suite Help 30.3.13.0

Documenting Exams

The Exams section on the Single Visit template has a grid that shows all exams recorded for the patient, and a list of exams that you can use to document exams performed in the current encounter. You can fill out as many different exams as needed for the patient on a single encounter. All data entered on any exam is displayed in the grid. Exams section in the Objective panel Access Exams Use Get Data to Fill in Exam Templates The Get Data button can help you enter patient information faster. Use a QuickPick to Fill in Exam Templates Open an Extra Exam or Special Test Template Enter Multi-Test Comparisons Compare Exams with Multiview View Exams Edit Exams Review Exams Parent topic: Objective Panel

NextGen® Orthopedic Suite Help 80.2.14.0

Document Pre-Operative History and Physical Examinations

You can review patient histories, document physical examinations, and add diagnosis details. On the Intake template, click the Non-Billable tab. The Navigation window opens. Select Pre-op H&P from the list, and click OK. The Pre-op H&P template opens. Note: The Patient is accompanied by field displays the data documented on the Intake template. You can change the value as needed. History panel on the Pre-op H and P template In the History panel, review the chief complaint, patient histories, medications, and allergies. Note: The fields in this panel are automatically filled with the data documented on the Intake template. You can document additional details or edit the details as needed. Enter the history of the present illness. In the Physical Exam panel, select an option from the left navigation bar, and document the physical examinations. Note: You can add or edit details in the following grids as needed. Vitals Today's Internal Radiology Orders Injections Outside Diagnostic Studies

NextGen® Therapy Suite Help 30.3.13.0

Exams

You can document on as many exams as necessary. To add exam information to the patient’s visit, select one of the exams from the left-hand list or select Additional to see, and then select other exams. Once you have added all necessary information on an Exam template, select Save & Close to close the template and save the information into the Exams grid on Single Visit. Exams grid Note: The left-hand list is configurable so you can remove exams that you will not use (for example, you may not see any Pediatric patients and, therefore, want to hide all Pediatric exams) or configure certain exams to show for specific therapists. The left navigation can be configured in the Navigation Config practice template. You can also compare multiple exams with the multi view option and view, edit, and review existing exams. Multi View Edit Review Student Mode Settings Parent topic: Speech Objective Panel

NextGen® Orthopedic Suite Help 80.2.14.0

Check Out Template

The Check Out template walks you through scheduling information from the patient visit: E & M Information displays the following: Status of the visit code on the Finalize Visit template and the visit type. Nurse case manager, if it was documented on the Check In template. Co-pay information. Cash Items- displays information from the Cash Supplies template and the green check mark indicates supplies were given and the total cost. Medications Prescribed or Renewed Today- displays medications entered in the current encounter. Next Visit Information- displays information from the encounter if the Upload NV button was selected on the Billable Visit, Fracture Care, or Non-Billable template. This informs staff to schedule an appointment in the NextGen® Enterprise PM. When you enter the Appt date, the content in the Details in EPM Appt are sent to the appointment details in the NextGen® Enterprise PM. Checkout Instructions- displays information if the C/O button on the Visit Type templates was

NextGen® Orthopedic Suite Help 80.2.14.0

Medical Decision Making

You can enter in the plan information. Each body area has its own plan section. The plan includes any verbal counseling done, medications, office procedures, diagnostic tests, labs, DME’s, patient education, and an area to designate follow-up visits. These fields are all picklist-driven and fully configurable within the Picklist Configuration template. You can enter data multiple different ways: Click each field to select items from configurable picklist. Click on the star or double star icons in the QuickPick Toolbar at the top of the Fracture Care template or from the MDM button that opens the MDM template to load a template default. Click the MDM button to launch a template where you can use the Get Data button to load MDM information from previous encounter. Parent topic: Assessment and Plan Panel for Poly Trauma

Document an Exam

Recommendations

Exams

Documenting Exams

Document Pre-Operative History and Physical Examinations

Exams

Check Out Template

Medical Decision Making

Exams

Documenting Exams

Document Pre-Operative History and Physical Examinations

Exams

Check Out Template

Medical Decision Making