Documenting Patient Encounters

NextGen® Orthopedic Suite Help 80.2.14.0

NextGen® Orthopedic Suite Home

You can use the Home template to access all the modules of the NextGen® Orthopedic Suite and view the summary of the medical and surgical history, medications, allergies, injections, and diagnostic tests for a patient. The recommended workflow is to begin a patient encounter on the Home template. From the Home template, you can use the workflow tabs and the links to access various templates of the NextGen® Orthopedic Suite. You can initiate a Scribe Encounter only on the Home template. You can also configure the Home template to exclude the radiology tests with the Cancelled or Error status in the All Internal Radiology Orders grid. For more information, go to NextGen Healthcare Success Community, and download the Configuration Guide for NextGen® Orthopedic Suite. Home template Note: If you are not on a checked-in encounter, the tabs in the workflow bar are grayed out. Access the Home Template You can open the Home template to begin workflows on the NextGen® Orthopedic Suite. Mark the

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

Order Referrals in the Referral Order Template

You can place referral orders for other specialties, providers, therapies, and durable medical equipment. Open the Home or any other applicable template, select Orders from the upper navigation bar, and then select Referral Order. The Referral Order template opens. To add diagnoses and procedures for the order, select Dx & Px. Note: Selecting procedures is optional; however, you must select at least one diagnosis to order referrals. Optional: To indicate that the referral is internal, select Internal referral. Select the date of injury and insurance name. Note: By default, the encounter date appears in Date. You can change the date, if needed. The policy number is automatically filled based on the selected insurance name. In the To section, do one of the following to select the recipient: To add a referral for a specialty or provider, select Specialty/specialist name/site, and then select the specialty, provider name, and reason. To add a referral for therapy, select Therapies/Rehabili

NextGen® Orthopedic Suite Help 80.2.14.0

Review and Update Mobile Dictation Data

You can review and update the mobile dictation data documented and sent to NextGen® Enterprise EHR through NextGen® Ambient Assist or any dictation software, such as NextGen® Mobile, NextGen® Direct-to-Desktop, or other third-party solutions. On any appropriate template, select the NG Mobile link. The NOS NG Mobile template opens. Note: The NG Mobile link is blue until mobile dictation data is documented. After you enter information on the NOS NG Mobile template and return to the current template, the NG Mobile link turns purple. Review and update the dictation data. Note: To update dictation data in a panel, you can modify the existing data in the field or use My Phrases. To associate the dictated results with an internal radiology order from the Diagnostic Interpretation panel, do one of the following: If radiology orders are configured to automatically update to Interpreted when marked as Performed, select the appropriate order from the left grid to mark it as Performed, and then se

NextGen® Orthopedic Suite Help 80.2.14.0

Using NextGen® Orthopedic Suite

You can use the NextGen® Orthopedic Suite templates to document the encounter details for different visit types of an orthopedic patient. Documenting Patient Encounters NextGen Orthopedic Suite Home You can use the Home template to access all the modules of the NextGen® Orthopedic Suite and view the summary of the medical and surgical history, medications, allergies, injections, and diagnostic tests for a patient. Patient Intake Details You can document the details of a patient for the provider's reference. Order Tests, Therapies, Equipment, and Referrals in the Single Order Template You can document the details of radiology, therapy, lab, durable medical equipment (DME), and referral orders required for a patient and place all orders at once. Order Lab Tests in the Lab Order Template You can place orders for lab tests performed and billed in your practice or at an external facility. Order Radiology Tests in the Radiology Order Template You can order radiology tests performed and bille

NextGen® Orthopedic Suite Help 80.2.14.0

NextGen® Orthopedic Suite Configuration

The Configuration Guide for NextGen® Orthopedic Suite, 80.2.14.0 explains how to configure various settings for NextGen® Orthopedic Suite. This document is intended for the staff who are responsible for maintaining the configuration settings. The minimum requirements for NextGen® Orthopedic Suite, 80.2.14.0 are as follows: NextGen® Enterprise EHR, 6.2021.1 NextGen® Adaptive Content Engine, 6.2021.1 (8.4.5.560) Microsoft SQL Server® 2016 Musculo Foundation INF 50.2.3.11 NextGen® Medication Inventory Control, 10.6.3.21 Specialty Configuration Home Parent topic: Configuring NextGen Orthopedic Suite

Documenting Patient Encounters

Recommendations

NextGen® Orthopedic Suite Home

Patient Intake Details

Order Referrals in the Referral Order Template

Review and Update Mobile Dictation Data

Using NextGen® Orthopedic Suite

NextGen® Orthopedic Suite Configuration

Documenting Patient Encounters

NextGen® Orthopedic Suite Home

Patient Intake Details

Order Referrals in the Referral Order Template

Review and Update Mobile Dictation Data

Using NextGen® Orthopedic Suite

NextGen® Orthopedic Suite Configuration