Loading...
Recommendations
Explore
Document Gynecologic History
Click the
LMP
date in the
LMP
field.
If the
LMP
was entered on the
Vital Signs
template, then it appears automatically.
Click the
Estimated
check box.
Select a date in the
Last pap
field.
If a Pap smear was entered in the
Pap smear
grid on the
Abnormal Pap HPI
or
OBGYN Synopsis
templates, the system fills in the date.
Click the
Patient reported
check box if applicable.
Click the
Last mammogram
field.
The
Historical Test – Quick Entry
template opens.
Select the applicable option from the
Mammogram
grid.
The
Test description
and
Test code
fields display the details of the selected option.
Select a date in the
Date done
field.
Entering a date value satisfies the Care Guidelines Mammogram entry.
Note:
The entered information displays in the
Diagnostic Studies
grid.
If appropriate, enter the interpretation and results in the
Interpretation
and
Results
fields. These are optional fields.
Click
Save & Add New
.
The date and test description displays in the
Historical tests/exams entered this visit
grid.
Click
Ok
.
Select the
Patient reported
check box.
Click
Save & Close
.
Verify that today's date appears in the
Last Clinical Breast Exam
field.
Note:
The date of last clinical breast exam is populated when it is documented in the
Physical exam
panel in the
SOAP
template.
Document Gynecologic History
NextGen® Adaptive Content Engine Help Enterprise 8
Document Pregnancy History
Select a field for the type of pregnancy. Select an amount from the numeric keypad. Click the Social History - Tobacco Use link and enter the applicable information. Click the Additional Screening link to enter the additional visit information in the Additional Visit Information Config practice template. For more information on configuring the additional visit information questions, refer to Open the Additional Visit Information Config Template section of the guide. Click the Adolescent Counseling link. Click the Parental Involvement Encouraged check box. Note: The Adolescent Counseling and Parental Involvement Encouraged fields may not appear for all patients. Click Save & Close. Parent topic: Document Family Planning Information in MA Intake Sub-Navigational Link
NextGen® Adaptive Content Engine Help Enterprise 8
Document the OBGYN Synopsis Template
The OBGYN link is available for female patients above the age of eight years. On the OBGYN Synopsis template, you can document information on the patient's menopause status, hysterectomy details, gynecological and pregnancy history, abnormal Pap, and contraception information. OBGYN Synopsis Note: The providers use OBGYN Synopsis only during a Gynecology visit and not during an OB prenatal visit. You can access the following templates from the OBGYN Synopsis template. Pap and HPV Details Pregnancy Outcomes Previous Pregnancy Problems OBGYN Confidential Info Social Hx On the Patient Information Card in NextGen® Enterprise EHR, select OBGYN. The OBGYN Synopsis template opens. Select the patient's Primary OBGYN provider. Select one of the following options. Detailed document. To include the gynecological and pregnancy histories in the document. Reviewed, no changes. If you have reviewed the details documented in the previous encounter and no changes were made. Reviewed, updated. If you ha
NextGen® Adaptive Content Engine Help Enterprise 8
Document a Physical Exam
The One Page Exam template is used to document a physical exam. Physical Exam panel You can examine a patient and document the information in the Physical Exam panel on the SOAP template. In the Physical Exam panel, you can, Use the One Page Exam to document the exam on the Gyn-PE template. On the Gyn-PE select the Normal check box to indicate normal findings for each system or click the Findings field to add any abnormal findings. Use other single system exam and its submenu in the left pane to document the corresponding exam details. When you click the single system exam or its submenu, the respective template opens. Use the Office Diagnostics button to document or review diagnostics and to place orders for the tests. Use the Quick Load or Quick Save button to load a saved default set or save a new default set. Use the Physical Exam History button to copy previous physical exam records to the current encounter. Document a Breast Palpation Physical Exam You can document the breast pal
NextGen® Adaptive Content Engine Help Enterprise 8
Review and Update Diagnostic Tests using the Historical Test – Quick Entry Template
You can review and update the historical tests performed previously for a patient using the Historical Test - Quick Entry template. Using the Historical Test – Quick Entry template, you can review, update, and comment on items that were entered by other staff members. To update diagnostic tests, do the following: Open NextGen® Enterprise EHR. Select the Care Guidelines link on any of the main template. The Care Guidelines Paged View template opens. In the Care Guidelines panel, select the Grid View link. The Care Guidelines grid view template opens. Select a appropriate study item in the Care Guidelines panel grid. Details for the guideline fill in the fields. Items with status due are ordered, such as labs and diagnostic studies. Care Guidelines In the Status field above the grid, select the status completed or performed elsewhere. The Historical Test – Quick Entry template opens. On the left side, select the appropriate test. The test description and orderable code values automatical
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
Complete the Derm Quick HPI Template
The Derm Quick HPI template enables you to enter the following patient information: General information about the patient's chief concern Dermatology specific information, including location of concern, skin type, cancer history and date of last exam Current and previous treatments Additional relevant details You can add up to six complaints on the HPI grid. In the Reason for Visit panel of the SOAP template, click derm quick hpi in the left pane. The Derm Quick HPI template opens. In the General panel, click the Concern field and select the patient's chief concern from the resulting list. To enter a duration for the concern, click the Duration field and use the resulting calculator. If this is a follow-up exam for treatment of the chief concern, click the Follow up check box. To select the current status of the concern, click Status. To indicate the date that the patient first noticed the concern, click Lesion noticed. If appropriate, select a Severity for the concern, either Mild, Mo
