Creating Patient Notes

Note Type	Description
Chart	A chart note is an informal used to document financial information concerning a patient. Any number of items can be stored in this informal format.
Encounter	An encounter note is a type of chart note used to document information about an encounter. Any notation about an encounter is saved under the Encounter - Note section.
Quicknotes	A Quicknote is a shorter, less extensive note and is easily accessible on-line. It is attached to the chart.

Help Guide for NextGen® Enterprise PM 8

Create Quicknotes

Open NextGen® Enterprise PM. On the main toolbar, select Chart or Chart Lookup . The Patient Lookup window opens. In the Search Criteria section, enter the patient's information, and then select Find. Patient records that match the search criteria, appear in the Matching Records section. Select the patient, and then select Open. The Patient Chart window opens. Select the Clinical History/Notes tab. The Clinical History/Notes window opens displaying Topics and Description. Under the Topics section, select the category to attach the note and then right-click in the Descriptions section and select Quicknote. The Quicknote window opens. Enter a subject for the note. Select a description for the user note from the User Note Description list. Note: User Note Descriptions are automatically filled text items that you can select when you create a note. Enter a description for the note in Note Entry. Select OK. Note: NextGen® Enterprise PM timestamps the create date, author of the note, and any

Help Guide for NextGen® Enterprise PM 8

Viewing Clinical History and Notes Information

In the Clinical History/Notes tab of the patient's chart, you can view encounter and chart related information for the patient arranged in different topics. You can do the following on the Topics and Details section of the Clinical History/ Notes tab of the Patient Chart window: Select a topic under Clinical History to view any stored information Print a claim status report from Clinical History View existing recall plans for the patient Create a note or quick note for the patient's chart Attach any note or quick note to mail Seal a note or quick note View order notes for NextGen® Optical Management orders Clinical History/Notes Tab Creating Patient Notes You can use three types of patient notes to record formal or informal information for the patient. Create Quicknotes You can use the Clinical History/Notes window to create a Quicknote. Parent topic: Patient Encounters and Financial History

Help Guide for NextGen® Enterprise PM 8

Add Notes to Encounters

Open NextGen® Enterprise PM. On the main toolbar, select Chart or Chart Lookup . The Patient Lookup window opens. In the Search Criteria section, enter the patient's information, and then select Find. Patient records that match the search criteria appear in the Matching Records section. Select the patient, and then select Open. The Patient Chart window opens. Select Encounters and then select the Notes tab under it. The Encounters and Encounter Notes sections appear. Under the Encounters section, select an encounter. Select open record and then select New. The Patient Note window opens. Patient Notes Window Enter details in Subject and Note Entry section, and then select OK. Note: You can select the Seal Note check box to seal and keep a note confidential. A pushpin appears on the Note tab along with the number of added encounters. Parent topic: Viewing Notes Information in Encounters

NextGen® Enterprise EHR Help

Add Sticky Notes

Sticky Note enables you to record patient-specific information, such as a future reminder to do a test, specific patient details to remember for the next visit, and more. The information does not print on the visit note document. Note: Recorded patient information from previous visits remains until manually erased. However, the database audit retains all patient information even after manual deletion. Open NextGen® Enterprise EHR, and select a patient from the Patient Lookup window. Select an encounter. On the Quick Buttons panel, select Sticky Note.The Patient Information window opens. In the Comments section, enter your notes, and then select Save & Close.The Sticky Note button changes to indicate that the selected encounter has saved the patient information. The Sticky Note supports up to 1000 characters. To view or edit saved patient information on an encounter, on the Quick Buttons panel, select Sticky Note. Note: You cannot edit saved patient information on locked encounters. Not

Help Guide for NextGen® Enterprise PM 8

Attach an Encounter Note to NextGen Mail

An encounter note can be attached to a NextGen Mail message and sent to other users. Access the Patient Chart. Select the Encounters tab. From the Encounters list, select an encounter with an existing quicknote. Select the Notes sub-tab. In the Encounter Notes section, select the note to be attached to a mail message. Right-click and select Attach to Mail. The New Message window appears The Subject field defaults to Patient Note - Enc #nnn and cannot be modified. Complete and send the mail message to the desired users. Parent topic: NextGen Mail

Help Guide for NextGen® Enterprise PM 8

Encounters in NextGen® Enterprise PM

An encounter is an interaction between a patient and a provider in the practice on a specific date and time. In NextGen® Enterprise PM, office encounters are typically created from the appointment book when each patient checks in for their appointment. Facility encounters that are not related to an appointment, such as hospital and nursing home visits, can be created from the patient's chart. Clinical information related to a specific encounter is documented by the provider in NextGen® Enterprise EHR. Financial information, such as charges, billing and transactions, is entered on that same encounter by users in NextGen® Enterprise PM. The Encounters tab on Patient Chart lists all encounters for a patient, and the Encounters Detail tab on Account Profile lists all encounters for a guarantor. For more information on encounters in NextGen® Enterprise EHR, go to the NextGen Healthcare Success Community and download the Layout and Preferences Guide for NextGen® Enterprise EHR. Encounter Sta

Creating Patient Notes

Recommendations

Create Quicknotes

Viewing Clinical History and Notes Information

Add Notes to Encounters

Add Sticky Notes

Attach an Encounter Note to NextGen Mail

Encounters in NextGen® Enterprise PM

Create Quicknotes

Viewing Clinical History and Notes Information

Add Notes to Encounters

Add Sticky Notes

Attach an Encounter Note to NextGen Mail

Encounters in NextGen® Enterprise PM