Pre-Operative History and Physical Exams

NextGen® Orthopedic Suite Help 80.2.14.0

Pre-Operative Visit for a Surgery

You can document the details of the pre-operative visit for a surgery. You can use the NB Preop v5 template to document the details of the pre-operative visit for the surgery, which is scheduled using the Surgery Sched template. The NB Preop v5 template has the following panels. You can also use the Get Data button fill the surgery details on this template from the previous encounter. History Physical Exam Assessment and Plan NB Preop V5 template Access the NB Preop V5 Template Document Patient History for Pre-Operative Visits You can document patient history such as surgery information, medications, allergies, and medical and surgical histories for pre-operative visits. Assessment and Plan (MDM) Panel Parent topic: Pre-Op Templates

NextGen® Orthopedic Suite Help 80.2.14.0

Generate the H&P Note

On the Pre-op H&P template, document the pre-operative history and physical exams. H and P document icon on the Pre-op H and P template Click the H&P Note document icon. The Pre-op H&P document generates. Parent topic: Pre-Operative History and Physical Exams Related tasks Document Pre-Operative History and Physical Examinations

NextGen® Orthopedic Suite Help 80.2.14.0

Pre-Op Templates

Access the FC Past Med Hx Template You can access the FC Past Med Hx template from the Home template. Document Past Medical History for Fracture Care You can document the pre-operative information for fracture care of patients. Pre-Operative Visit for a Surgery You can document the details of the pre-operative visit for a surgery. 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. Submitting Charges to Finalize a Visit You can enter the visit details, today's diagnoses, and procedures to submit charges and finalize visit. Parent topic: Using NextGen Orthopedic Suite

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® Adaptive Content Engine Help Enterprise 8.3.1

Document Orthopedic Pre-Op Visit Details

From the navigation bar, click the Pre Op Visit link. The Preop Visit template opens. Preop Visit The Preop visit template displays the assessment, orders, medication, and allergies details documented in the Intake and SOAP templates. Click the Schedule Procedure button to enter the surgery information. The Ort Surgery Scheduling template opens. Enter the applicable details in the Procedure, Laboratory Tests, Diagnostics Studies, and/or Surgery Details sections in the Ort Surgery Scheduling template. The documented details are displayed in the Surgery Orders grid. Document the Consents information. In the Preop Studies section, record and review Labs, Diagnostics, and Referrals. Click Add Historical Orders to add diagnostic history. Click Preview Document to generate the document in runtime. Parent topic: Orthopedic Pre-Op Visits

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

The Pre-procedure Evaluation panel allows you to view and add patient's physical exam findings and generate the ASC Chart Note document after review and signoff. You can use the My Phrases link at the top-right of the Comments field to add comments. For more information on managing and using the My Phrases functionality, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. After entering the appropriate data in the Physical Exam, select the No or Yes option for the Patient remains an appropriate candidate to undergo the planned procedure checbox to indicate whether or not the physician can consider performing any further planned procedures on the patient. The following options are available at the bottom of the Pre-Procedure Evaluation panel: Normal history and physical - Indicates that the pre-procedure evaluation findings are normal. History and physical reviewed, no changes - Indicates that the existing pre-pro

Pre-Operative History and Physical Exams

Recommendations

Pre-Operative Visit for a Surgery

Generate the H&P Note

Pre-Op Templates

Document Pre-Operative History and Physical Examinations

Document Orthopedic Pre-Op Visit Details

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template

Pre-Operative History and Physical Exams

Pre-Operative Visit for a Surgery

Generate the H&P Note

Pre-Op Templates

Document Pre-Operative History and Physical Examinations

Document Orthopedic Pre-Op Visit Details

Pre-Procedure Evaluation Panel on the ASC - Physician Procedure Template