Patient History for Post-Operative Visits

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

NextGen® Orthopedic Suite Help 80.2.14.0

Submitting Charges to Finalize a Visit

You can enter the visit details, today's diagnoses, and procedures to submit charges and finalize visit. You can use various sections on the Finalize Visit template to add data and submit charges for finalizing a visit. In the Non-Billable & Initial Fracture Care grid, you can select the appropriate option for the current workflow to add it to the coding grid. When you select any option except No services rendered in the Non-Billable & Initial Fracture Care grid, the IORTSfinalize Po window opens for entering the dictation used for any part of the visit. If dictation is not configured for the provider or the practice, the IORTSfinalize Po window does not open. For the options that have associated task configured, the Add New Task window opens before the IORTSfinalize Po window. After you assign the task to the desired user or work group and close the Add New Task window, the IORTSfinalize Po window opens. If no services are provided to the patient, you can select No services rendered,

NextGen® Orthopedic Suite Help 80.2.14.0

Assessment and Plan for Non-Billable Post Op Visits

The Assessment and Plan panel allows the provider to document a post-op visit for an initial fracture care procedure, the plan, verbal counseling, and next visit information. The Diagnosis grid displays the patient’s diagnoses. The system defaults to the Orthopedic option to view Orthopedic-specific diagnoses. The Medical option displays non-orthopedic diagnoses. Assessment and Plan panel on the NBV Single Fx template Add Today’s Diagnosis Medical Decision Making Sign-Off Parent topic: Non-Billable Fracture Care Post-Op Workflow

NextGen® Orthopedic Suite Help 80.2.14.0

Document Patient History for Post-Operative Visits

You can document a patient's history such as details of the last injection, pain, medications, and allergies for a post-operative visit. On the Non Billable Visit template, expand the History panel. Enter the details of the last injection in the following order: Click the Last Inj field, select the last injection date, and then click OK. Enter the duration of the relief in hours, days, weeks, and months. Enter the details of pain as follows: Indicate the severity of the pain. Click the Pain Scale field, and select the pain scale from one to ten from the list. Click the Status % field, select the percentage of the pain status, and then click OK. Select one of the following to indicate the pain status. B. Better S. Same W. Worse In the Ambulatory Aids/Braces, Assoc Symp, and Function/Activity Level sections, do the following: Click the blank field, select the appropriate condition from the window, and then click OK. Indicate the applicability of the selected condition. Note: You can ente

NextGen® Orthopedic Suite Help 80.2.14.0

Non-Billable Fracture Care Post-Op Workflow

Each fracture care template has a corresponding non-billable fracture care template such as NBV Single Fx, NBV Multiple FX, and NBV Poly-Trauma FX follow-up. The non-billable fracture care templates are accessed by clicking the Non-Billable tab and selecting the desired template. These templates enable you to document a follow-up visit for the initial fracture care visit. Each of these templates has four panels; Surgical Information, History, Physical Exam, and Assessment and Plan. Copy Previous Surgery Details You can copy details of previous surgeries for assessment and planning of the polytrauma fracture care on the NBV PolyTrauma template. Patient History for Post-Operative Visits You can associate surgical procedures with post-operative visits, and document a patient's history for post-operative visits. Physical Exam Panel Assessment and Plan for Non-Billable Post Op Visits Assessment and Plan Panel- NBV Multiple FX Assessment and Plan Panel - NBV Polytrauma FX Submitting Charges

Patient History for Post-Operative Visits

Recommendations

Patient Intake Details

Physical Exam Panel

Submitting Charges to Finalize a Visit

Assessment and Plan for Non-Billable Post Op Visits

Document Patient History for Post-Operative Visits

Non-Billable Fracture Care Post-Op Workflow

Patient Intake Details

Physical Exam Panel

Submitting Charges to Finalize a Visit

Assessment and Plan for Non-Billable Post Op Visits

Document Patient History for Post-Operative Visits

Non-Billable Fracture Care Post-Op Workflow