Document Pre-Operative History and Physical Examinations

NextGen® Orthopedic Suite Help 80.2.14.0

Document Providers and Patient Histories for Preregistration

You can add patient histories and the details of the providers for preregistration of a patient. On the Pre Reg template, click the Clinical 1 tab. The Clinical 1 template opens. Clinical 1 template Note: The fields in the Appointment, Contact Information, and Best Time sections are automatically filled with the values on the Pre Reg template. You can update the fields below Best Time. Double-click the Pharmacy field. The Preferred Pharmacy window opens. Add the preferred pharmacy for the patient. Review the preferred pharmacy, and select Reviewed. Review the following details, and select All Reviewed. Appointment Pharmacy Contact Information Best Time In the Providers panel, add the details of the providers and shared care facilities. Providers panel on the Clinical 1 template To enter the details of previous treatments, do the following: Click Previous Treatment. The IORTSprev Treatment window opens. IORTS Previous Treatment window Type the details of the previous treatments. Select

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

Document Past Medical History for Fracture Care

You can document the pre-operative information for fracture care of patients. You can use the FC Past Med Hx template in the fracture care workflow to document a patient's history and pre-surgical checklist for fracture care procedures. On the FC Past Med Hx template, click the Chief Complaint field, and select the reason for visit from the list. The lists open for selecting side of the body, body part, and complaint. Select the affected side of the body, body part, and complaint from the corresponding lists. Add or update the pharmacy, as needed. Make the desired changes in the following sections. Diagnosis Orthopedic Surgical History Allergies Medical History Surgical History Medications Social History Family History Review of Systems Note: These sections are automatically filled with the data documented on the Intake template. You can add, edit, and remove the data as needed. To add details of the patient's employer, click Add below the Employer field. In the Pre-Surgical Checklist

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® Orthopedic Suite Help 80.2.14.0

Physical Exam Panel

The Physical Exam panel appears on the Billable Visit template, the Fracture Care templates, the Non-Billable Visit template, and the Non-Billable Fracture Care templates. The left navigation bar has links to all physical exams, with the ones most pertinent to the current workflow at the top. Physical Exam panel on the Billable Visit, Fracture Care, and Non Billable Visit templates Vitals Exams Today's Internal Radiology Order Grid Outside Diagnostic Studies Document and Injection or Aspiration Documenting Office Procedures You can document various procedures that are performed in the office. Document Cash and Carry Supplies Complete the Medicare ABN Form Parent topic: Billable Visits Parent topic: Non-Billable Post-Op Visit Workflow Parent topic: Non-Billable Fracture Care Post-Op Workflow

Document Pre-Operative History and Physical Examinations

Recommendations

Document Providers and Patient Histories for Preregistration

Patient History

Document Past Medical History for Fracture Care

Pre-Operative History and Physical Exams

Patient Intake Details

Physical Exam Panel

Document Providers and Patient Histories for Preregistration

Patient History

Document Past Medical History for Fracture Care

Pre-Operative History and Physical Exams

Patient Intake Details

Physical Exam Panel