Patient History

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® 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

NextGen® Orthopedic Suite Help 80.2.14.0

Billable Visits

The Billable Visit workflow starts on the Billable Visit template. This template is used to document the History of Present Illness (HPI), Physical Exams, and Assessment and Plan portions of an E&M coded visit. It pulls in information from the Intake template. It has three panels: History, Physical Exam, and Assessment and Plan. Documenting Visit Time You can enter the visit time for a patient's visit on the Billable Visit template. Patient History You can review, add, and update the patient histories. Physical Exam Panel Assessment and Plan Panel (Diagnosis/MDM) Billable Visit Sign-off Documenting Billable Visit Counseling You can document the additional counseling time and its associated details for a patient. Finalizing a Patient Visit You can enter a patient's visit details and today's diagnoses, and apply diagnosis codes to procedures to submit charges and finalize the visit. Parent topic: Using NextGen Orthopedic Suite

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

Add a Chief Complaint

You can add up to six chief complaints. If the patient has complaints that were not captured on Intake, you can add them on Billable Visit. Click on a blank HPI # link. The first of a series of picklists opens. Select items in the picklists. Each selection opens the next picklist. Picklists for chief complaint When you have selected an item in the fourth picklist, or at any time that you click Close, the picklists close. To type a complaint, click the Free Text button. The IORTShpi Freetext Mr template opens. Chief complaint text Click any Chief Complaint field to add text to describe the complaint and click Save & Close. Edit or Delete a Chief Complaint Parent topic: Patient History

NextGen® Adaptive Content Engine Help Enterprise 8

Patient's History Summary

The History Summary panel on the Intake template enables you to document a patient's past medical or surgical history, interim, social, family, and diagnostic study. It also displays the patient history documented by the Intake staff on the Histories template. You can add diagnostic studies with a documented Result or Interpretation to the grid in the Reason for Visit panel by clicking the Add to HPI Grid button. The grid includes a list of categories in the left pane to select and view the documented data. You can filter the patient history records by selecting the Medical History or Surgical History option. Parent topic: Intake Template

Patient History

Recommendations

Document Pre-Operative History and Physical Examinations

Document HPI of Patients

Billable Visits

Patient Intake Details

Add a Chief Complaint

Patient's History Summary

Document Pre-Operative History and Physical Examinations

Document HPI of Patients

Billable Visits

Patient Intake Details

Add a Chief Complaint

Patient's History Summary