Document Pre-Operative History and Physical Examinations

NextGen® Orthopedic Suite Help 80.2.14.0

Patient History

You can review, add, and update the patient histories. The History panel on the Billable Visit template enables you to select the visit type and review the diagnoses, histories, medications, allergies, and review of systems of a patient. You can also add or update the details of the history of present illness (HPI). The following grids are automatically filled with the data documented on the Intake template. You can add, edit, and remove the data as needed. Diagnosis Orthopedic Surgical History Allergies Medical History Surgical History Medications Social History Family History Review of Systems History panel on the Billable Visit template Visit Type Quick Visit Add a Chief Complaint Document HPI of Patients You can document a history of present illness (HPI) for chief complaints. Signing Off Patient Histories After you review and update the patient histories, you can sign off the data to bill for the visit. Parent topic: Billable Visits Related concepts Patient Intake Details

NextGen® Orthopedic Suite Help 80.2.14.0

Pre-Operative History and Physical Exams

The Pre-op H&P template enables you to document the details of H&P exams and generate the H&P Note. You can use the Pre-op H&P template to review the patient history, document physical exams, and add diagnosis details before surgery. It is also used to generate the H&P Note document. This template consists of the following panels. History Physical Exam Diagnosis Pre-op H and P template Document Pre-Operative History and Physical Examinations You can review patient histories, document physical examinations, and add diagnosis details. Generate the H&P Note You can generate the H&P Note for the pre-operative history and physical exams. Parent topic: Pre-Op Templates

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

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Intake Template

You can use the Intake template to document the patient information. You can document the following details of the patient in the various sections of the Intake template: General information of the patient Reason for the patient's to visit Patient's history Patient's Assessments Patient Medications Patient's allergies Vital Signs Patient's Orders Review of systems Patient Education Start a Dermatology Encounter Patient's General Information You can document a patient's general information on the Intake template. Add a Reason for Visit You can document the History of Present Illness (HPI), problems, as the reason for a patient visit. Patient's History Summary Patient's Assessment You can view patient's assessments. Patient Medication You can document and manage a patient's medications. Adding and Reviewing Allergies You can add and review the allergy details associated with a patient in the Allergies panel. Documenting Vital Signs You can document and update a patient's vital signs on t

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Pre-Operative Visit Details

You can document the details and recommend any test for a patient before surgery. On the Preop Visit template, you can record the health condition and recommend any test for a patient. You can refer to other doctors to make sure that the patient's condition is stable before the surgery. In the left Navigation bar, select Pre Op Visit.The Preop visit template opens displaying the assessment, orders, medication, and allergies details documented on the Intake and SOAP templates. Preop Visit To enter the surgery details, select Schedule Procedures.The Surgery Orders grid displays the details of the scheduled surgery. In the Consents section, do the following: Select the appropriate option after explaining the procedure details to the patient. Select Risk detail, and select the relevant pre-operative risks. Select the appropriate option for Agrees to blood/blood products?If you select no, select the Signed blood/blood product refusal form check box. To open the Preop Checklist template, sel

NextGen® Orthopedic Suite Help 80.2.14.0

Document HPI of Patients

You can document a history of present illness (HPI) for chief complaints. On the Billable Visit template, in the History panel, click on any chief complaint. The IORTShpi window opens displaying the corresponding HPI tab. IORTS HPI template Note: To document a different chief complaint, you can click the desired HPI tab. The Procedures grid displays the details from the Orthopedic Surgical History section on the Billable Visit template. Do one of the following to enter the patient's HPI. Click Get Data, select the desired encounter to copy the details from the scope window, and then click OK. In the QuickPick toolbar, click the Star icon or Double star icon icon, select the desired set name from the filter window, and then click OK. Select the appropriate options and enter the details in the fields. To add details of the patient's employer, click Add below the Employer field. To add the sports details and hobbies of the patient, double-click the corresponding field. Make the desired ch

Document Pre-Operative History and Physical Examinations

Recommendations

Patient History

Pre-Operative History and Physical Exams

Patient Intake Details

Intake Template

Document Pre-Operative Visit Details

Document HPI of Patients

Patient History

Pre-Operative History and Physical Exams

Patient Intake Details

Intake Template

Document Pre-Operative Visit Details

Document HPI of Patients