Pre-Operative Visit for a Surgery

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

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. On the NB Preop v5 template, in the History panel, click the Get button. History panel on the NB Preop V5 template The surgery window opens displaying all surgery encounters with planned procedures for the patient. Select an encounter from the surgery window, and click OK. The following details from the selected encounter are automatically filled in the corresponding fields. The options in the Pre-Surgical Checklist section are automatically updated from the Surgery Sched template on the selected encounter. Clearance Boarded procedures Pre-Op and post-op medications Medication instructions Anesthesia provided Labs and tests To add additional medications and instructions, click the desired fields, and then select the option to be added from the list. To generate a revised medication instruction, click the Create Document Document icon icon. I

NextGen® Orthopedic Suite Help 80.2.14.0

Access the NB Preop V5 Template

On the Home template, click the Non-Billable tab. The Navigation window opens. Select Pre-op V5 from the list. The NB Preop v5 template opens. Parent topic: Pre-Operative Visit for a Surgery Related tasks Access the Home Template

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

Assessment and Plan (MDM) Panel

The Assessment and Plan panel enables the provider to select the diagnosis for today’s plan, enter today’s plan in, next visit information, and verbal counseling. Assessment and Plan panel on the NB Preop V5 template The Diagnosis grid displays the patient’s diagnoses. The filter options default to Orthopedic to view the patient’s orthopedic-specific diagnoses. Select Medical to view additional diagnoses. To add a diagnosis for today’s visit, select the diagnosis from the grid. Note: If a diagnosis is not listed in the grid, click Add to launch the Common Assessments template or Problem IT to launch the IMO template. The diagnosis is moved to a Today’s Diagnosis field. You can enter items in the Management, Instructions and Overflow fields by using the configurable picklists or using the default save functionality referred to as a QuickPick. Enter Verbal Counseling or use My Phrases. The provider can sign off on the NB Preop v5 template, by clicking the Electronically Signed By check b

NextGen® Adaptive Content Engine Help Enterprise 8

Document Orthopedic Pre-Op Visit Details

From the navigation bar, click the Pre Op Visit link. The Preop Visit template appears. 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 appears. 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

Pre-Operative Visit for a Surgery

Recommendations

Pre-Operative History and Physical Exams

Document Patient History for Pre-Operative Visits

Access the NB Preop V5 Template

Pre-Op Templates

Assessment and Plan (MDM) Panel

Document Orthopedic Pre-Op Visit Details

Pre-Operative Visit for a Surgery

Pre-Operative History and Physical Exams

Document Patient History for Pre-Operative Visits

Access the NB Preop V5 Template

Pre-Op Templates

Assessment and Plan (MDM) Panel

Document Orthopedic Pre-Op Visit Details