NextGen KBM Dermatology User Guide. Version 8.3

NextGen

®

KBM

Dermatology User Guide

Copyright © 2013 NextGen Healthcare Information Systems, LLC. All Rights Reserved.

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In as much as possible, default procedures in this guide were developed using the most current Microsoft operating system and most current Microsoft server operating system. When required, procedures in this guide were developed based on the Microsoft Windows 7 operating system and/or Windows Server 2008 and SQL Server 2008, unless otherwise noted. Screen shots in this document were primarily developed using the Windows 7, Windows Server 2008 and SQL Server 2008 systems. Note: Other Windows operating systems that support this product may work differently.

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NextGen® Ambulatory EHR NextGen® Dashboard NextGen® EHR Connect

Insight Reporting™ NextGen® HIE NextGen® HQM

NextGen® KBM NextGen® Mobile NextGen® Patient Portal

NextPen® NextGen® Appointment

Scheduling

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Management

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The following terms may be used interchangeably throughout this document: NextGen Ambulatory EHR and NextGen EHR

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Document Revision History

Contents

Chapter 1

Introduction

9

Requirements ... 9

Configuration and Setup Procedures

11

The Joint Commission Standards Configuration ... 11

Reason for Visit Configuration ... 12

Sub-Navigational Links ... 13

General Office Visit Workflow

15

Patient Information Bar ... 15

Active Text Links (NextGen KBM 8.3 Dermatology) ... 17

Alerts ... 21

Panel Controls ... 22

Quality Buttons and CQM Information Pop-up Templates ... 23

Care Guidelines ... 24

Global Days ... 25

Screening Tools and Document Library ... 26

Intake Staff Workflow

29

Home Page - Dermatology Template ... 29

Home Page Sub-Navigational Links ... 30

Demographics Sub-Navigational Link ... 30

Call/Communication Sub-Navigational Link ... 31

Provider Test Action Sub-Navigational Link ... 32

Orders Management Sub-Navigational Link ... 33

Document Library Sub-Navigational Link ... 34

Risk Indicators (NextGen KBM 8.3 Dermatology) ... 35

Intake Template ... 35

Intake Sub-navigational Links (NextGen KBM 8.3 Dermatology) ... 35

General Panel ... 42

History of Present Illness Panel ... 42

Medications ... 43

Medication Reconciliation for a Patient ... 44

Allergies ... 45

Vital Signs Panel ... 46

Health Promotion Plan Template ... 47

Orders Panel ... 51

Point of Care Tests ... 53

Histories Template ... 55

Histories Sub-navigational Links (NextGen KBM 8.3 Dermatology) ... 55

Skin Cancer History Log ... 57

Problem List Panel ... 58

Problem List Panel ... 61

History Summary Panel ... 62

Social History – Tobacco Template ... 63

Family History ... 66

Diagnostic Studies ... 68

History Review ... 69

Intake Note Generation ... 70

Patient Tracking ... 71

Provider Workflow

75

Patient Tracking ... 75

Home Page - Provider Review ... 75

Panels on the Dermatology Home Page Template ... 75

History Summary Panel on the Home Page Template ... 78

Allergies Panel on the Home Page Template ... 78

Medications Panel on the Home Page Template ... 78

Vital Signs Panel on the Home Page Template ... 79

Orders Panel on the Home Page Template ... 79

Communication Panel on the Home Page Template ... 79

Document SOAP (NextGen KBM 8.3 Dermatology) ... 79

Compose Introduction ... 80

Quick Note ... 80

Reason for Visit on the SOAP Template (NextGen KBM 8.3 Dermatology) ... 80

Review of Systems on the SOAP Template (NextGen KBM 8.3 Dermatology) ... 82

Vital Signs on the SOAP Template ... 83

Physical Exam Panel (NextGen KBM 8.3 Dermatology) ... 83

Create Assessment/Plan (NextGen KBM 8.3 Dermatology) ... 84

SOAP Link Icons ... 86

Save Quick Note ... 86

Generate Note ... 87

Finalize Template ... 87

Finalize Tab Sub-Navigational Links (Derm) ... 88

Tobacco Cessation Sub-Navigational Link ... 88

General Panel ... 89

Today's Assessment Panel (NextGen 8.3 KBM Dermatology) ... 89

Provider Sign Off Panel ... 89

Evaluation and Management Coding Panel ... 89

E & M Level Summary Panel ... 92

History Details ... 92

Evaluation and Management Guidelines ... 93

97 Single System Physical Exam Details Panel ... 93

Dermatology Procedure Billing Panel ... 94

Checkout Staff Workflow

97

Checkout Template (NextGen KBM 8.3 Dermatology) ... 97

Today's Orders Panel ... 98

Send Tasks ... 99

Given to Patient/Verified Panel ... 100

Patient Tracking - Check Out ... 101

Generate Note ... 101

Procedure Template and Skin Cancer History Grid

103

Using the Procedure Template and Skin Cancer History Grid ... 103

Derm Quick HPI

105

Using the Derm Quick HPI ... 105

New Codes for Dermatology Assessment

107

New Codes on Dermatology Common Assessment ... 107

Excision Template

109

Using the Excision Template ... 109

Biopsy Log

111

Using the Biopsy Log ... 111

Mohs Templates

113

Using the Mohs Templates ... 113

Index

115

This user guide contains an overview of the NextGen KBM 8.3 framework for the Dermatology specialty. It provides users with instructions on using the templates. This document is not intended as instructions for entering patient information or using the system for a live patient but rather is

designed to explain how to use the templates.

This chapter provides information about the organization and purpose of this user guide. It defines the audience, provides a general overview of the topics covered in this guide, and lists assumptions about the level of knowledge required for this guide.

This guide assumes that you have basic knowledge and skills for all of the following: Microsoft Windows operating systems

Microsoft Office applications

All applicable NextGen ambulatory products

Requirements

The prerequisites for completing the instructions in the guide include: 1 Installation and configuration of the NextGen Ambulatory EHR. 2 A valid user ID and password to log on to the system.

Note: This guide was created using NextGen Ambulatory EHR, Version 5.8.0.100 and NextGen KBM

Version 8.3.

Slight variations in the steps performed and the graphic images and screens depicted may occur depending on what versions of NextGen Ambulatory EHR and NextGen KBM you may be using. The fundamental concepts will remain the same.

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This section provides information on the necessary settings that are required to begin the office visit workflow for the specialty, including configuration of the Joint Commission standards and the Reason for Visit/History of Present Illness (HPI) template.

The Joint Commission Standards Configuration

The Joint Commission standards configuration setting for all NextGen KBM templates is found on the

Ngkbm Config practice template. If you enable the Joint Commission standards in the Ngkbm Config

practice template, all fields and links related to the Joint Commission are enabled.

When you enable the Joint Commission standards, you need to document and review the patient allergy information before recording any other patient data during the encounter.

To set the Joint Commission standards settings: 1 Log on to NextGen Ambulatory EHR.

Reference: For more information on how to log on to the NextGen Ambulatory EHR, refer to the

NextGen Ambulatory EHR and Practice Management Logon Guide.

2 From the File menu, select System/Practice Template.

The Select Template dialog box displays.

3 Click the Practice tab. 4 In the Show section, click All.

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A list of templates displays.

5 Double-click Ngkbm Config.

The Practice Preferences template displays.

6 In The Joint Commission Standards row, clear or select the Enable The Joint Commission requirements check box.

7 Close the Practice Preferences template and click Yes when prompted to save the changes.

Reason for Visit Configuration

A practice can customize the Reason for Visit panel of the Intake and SOAP templates in the Ngkbm

Framework Content system template.

To configure the reasons for visit: 1 Log on to NextGen Ambulatory EHR.

2 From the File menu, select System/Practice Template.

The Select Template dialog box displays.

3 In the Show section, click the All option.

4 Double-click Ngkbm Framework Content to access the Ngkbm Framework Content template.

5 Click the Specialty list to access the picklist.

6 Select your specialty to view all of the configurable content. 7 In the Reason for Visit panel, click the all option for Filter.

8 Click the first drop-down arrow to access the Ngkbm Udp Custom Link Filter picklist.

9 Highlight the reason for visit, linked to the appropriate HPI, that you wish to add to the Reason for Visit list.

10 Click OK.

11 Click the second drop-down arrow to access the Gender picklist. NOTE: Gender is required in order to add a reason for visit to the list.

12 Select All from the picklist to indicate that the selected reason applies to all genders or select a

specific gender.

13 Click Add.

The newly added reason for visit is included in the data grid.

14 Click the Save icon on the top toolbar.

The selected reason for visit displays in the Reason For Visit pop-up template launched from the

Additional/Manage active text link in the Intake template.

Sub-Navigational Links

NextGen KBM 8.3 includes navigational links that appear beneath the tabs. If you click a sub-navigational link, the corresponding pop-up template opens. The links can be customized by the following:

Specialty Practice Provider

Specialty and practice Specialty and provider

The sub-navigational links are associated with a particular tab so that different links can appear on various tabs. To configure the sub-navigational links, go to the Ngkbm_framework_content system template.

This section describes about the general office visit workflow for this specialty. It also provides:

Steps to set the Home Page template as the default template. Overview of the Patient Information Bar.

Brief description of Panel Controls, Care Guidelines, and Global Days.

The general office visit workflow includes the intake staff workflow, provider workflow and checkout staff workflow, which involves:

Documenting the Reason for Visit/HPI, Vital Signs, Medications, Allergies, Physical Exams, and Assessment Plans for the patient.

Finalizing the workflow and generating a detailed report of the encounter.

Patient Information Bar

The Patient Information bar displays in NextGen Ambulatory EHR above the current open module or template. The bar remains visible regardless of the module or template that is open. To access the Patient Information bar, you must first make it available and configure it in the Patient Information Bar Practice Preference.

Reference: For information on how to configure the Patient Information bar, refer to the Patient Information Bar Practice Preferences section in the NextGen® Ambulatory Products Administrator

Guide.

The arrow beside the Medications field is used to minimize or maximize the view of Patient Information bar.

The Patient Information bar includes patient's first name, middle initial, last name followed by the gender, date of birth and age.

The Patient Information bar is divided into the following parts:

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Patient Summary Medical Information Patient General Information

Patient Demographic Information Encounter Based Information

Patient Summary Medical Information - This includes the list of Allergies, Problems, Diagnoses, and

Medications of the patient.

You can click the number beside the Allergies, Problems, Diagnoses, and Medications fields to display the respective modules. When you hover your mouse over the number beside each field, the label changes color and displays the corresponding lists of allergies, problems, diagnosis, and medications.

The Alerts button is used to add or view patient alerts. If the patient has any alerts, the Alerts button will display in red.

Patient General Information - This includes Send Email , Telephone Call , To Do , and Patient

Tracking icons, which allows you to send an email, document a phone conversation or a walk-in

patient encounter outside a visit, send a task to someone, or track the time that the patient spent in the office. The Patient General Information section also includes the patient's address and contact

information.

Reference: For more information on these icons, refer to the Patient General Information section in the

NextGen Ambulatory EHR Getting Started Guide, Version 5.8.

Patient Demographics Information - This includes information on Insurance, Enterprise Chart

Indicator, MRN, Parent/Guardian, etc.

Encounter Based Information - This includes information on the primary care provider, referring

provider, and rendering provider.

The bottom portion of the Patient Information bar includes the following active text links: Sticky Note

Referring Provider HIPAA

Advance Directives Screening Summary

OBGYN Details (available for female patients over 12 years of age)

You can also includes any three fields from the demographic templates, which are set up by the practice in File Maintenance.

Active Text Links (NextGen KBM 8.3 Dermatology)

The patient header includes various active text links to document additional information about the patient.

Nxmd Demographics

The Nxmd Demographics active text link displays the Patient Portal - Demographics template where you can document the patient's address and contact details, including emergency contact information.

Order Administration

The Order Administration active text link displays the Order Administration template, which displays a list of the orders and their status. When you highlight an order in the Order section, the details of the order display in the Order details section.

OBGYN Detail

The OBGYN Detail active text link is available for female patients above 12 years of age and launches the OBGYN Synopsis template. You can document menopausal status, hysterectomy details,

Sticky Note

The Sticky Note active text link displays the Patient Information dialog box where you can enter social information about the patient. The information entered in the Patient Information dialog box is not printed on the chart note.

Referring Provider

The Referring Provider active text link displays the Patient Providers dialog box that includes the details of the primary care provider and encounter provider. You can also enter additional referring provider details and select the providers whose details should be listed at the bottom of the chart note.

HIPAA

The HIPAA active text link displays the HIPAA Disclosure Information dialog box where you can document the authorization provided by the patient or the legal guardian to disclose protected health information. The HIPAA Information section in the HIPAA Disclosure Information dialog box is completed by the intake staff.

Advance Directives

The Advance Directives active text link displays the Advance Directives dialog box where you can document the discussion had with the patient about advance directives. You can also document name and contact information for a healthcare proxy and durable power of attorney.

Screening Summary

The Screening Summary active text link displays the Screening Summary dialog box. In the Screening

Summary dialog box, you can document pain severity and assessment method. The Social History

section enables you to document information on patient's nutrition, tobacco use, alcohol use, caffeine use, and drug abuse. The Counseling/Educational Factors active text link in the Counseling section allows you to document details about the type of counseling offered to the patient. In the Screenings section, you can document when the patient had the last PAP smear, hearing screening, and last mammogram.

Alerts

The Patient Information Bar includes the Alerts button to inform providers of the specific concerns about the current patient.

To document specific concerns about the patient:

1 Click the Alerts button to access the Add Alert pop-up template.

2 Select the appropriate check boxes to provide alerts to the providers. For example, select the Bed-ridden check box to add an alert for possible fall risk.

3 If the required alert is not available, select the Other check box and then select a value from the Alerts other picklist.

If the appropriate alert does not appear in the list, click on the top blank row of the picklist to enter a value in the associated field.

Note: The Pregnant field is available for female patients. This is used in multi-specialty practices

to alert non-obstetric providers that the patient is pregnant.

The Suicide/Homicide Risk active text link opens the Safety Risk pop-up template, which is used by some specialties to document suicide or homicide risk during a patient encounter.

Panel Controls

Panels display information according to type such as Vital Signs or Allergies. Templates can contain one or more panels used for viewing existing information and documenting new information. Panels allow users to customize the order that information appears on a template. To change the order of the panels, users can click on the title bar of a panel and drag it to a different position on the template. If a user changes the order of the panels, they will remain in that order from patient to patient until the order is changed again.

Users can expand and collapse panels so that they can view the panels containing only the most pertinent information. Users can also use Cycle buttons to scroll through all of the panels on the template.

The Panel Controls section includes two pairs of icons. The Toggle icons expand and collapse all the panels and the Cycle icons rotate the panels through all positions from top to bottom, one position at a time.

The Cycle Down icon is used to move the bottom panel to the top and expand it while collapsing all other panels. The Cycle Up icon is used to move the top panel to the bottom and expand the panel that moved to the top position.

If you visit another tab in the workflow and return to the one on which the Cycle feature has been applied, the panels remains in the applied order. To reset the panels to the original state, right-click in the blank area to the right of the template and select Panel Defaults.

Quality Buttons and CQM Information Pop-up

Templates

Quality buttons have been added to various places in NextGen KBM 8.3. When clicked, the Quality

buttons launch information pop-up templates containing information about documenting the associated clinical quality measure.

For example, all templates with the Patient Status - Transitioning into care and Patient Status -

Summary of care received check boxes have a Quality button.

Care Guidelines

The Care Guidelines active text link is available from all of the templates.

The Care Guidelines pop-up template allows you to verify or update information related to lab or radiology order processing, clinical guidelines, screening questions, vital signs, immunizations, nutrition, and drug therapy.

The CQM check runs when you open the Care Guidelines template. When you click the CQM Check button in the blue panel on the left side, the CQM Results template opens. On the Care Guidelines template, a description of the measures and what passed and failed appears below the button.

Reference: For detailed information on Care Guidelines, refer to the NextGen KBM Clinical

Guidelines, Protocols and Recommended Care Version 8.3 White Paper.

Global Days

The Global Days feature tracks the number of post-op days remaining for a patient who has had a recent surgical procedure. This feature displays the procedure or surgeries for a patient with the associated post-op days. The calculation of Global Days is based on the CPT®4 code and the post-op days configured in NextGen File Maintenance.

The Global Days active text link opens the Global Days pop-up template where you can verify, add or update information related to assessment code, procedure, and procedure dates.

To manage global days:

You can use the Global Days pop-up template to verify, add, or update information related to assessment, code, procedure, and procedure dates.

2 Click Save & Close.

Screening Tools and Document Library

The Screening Tools pop-up template contains various screening and assessment tools that can be used during a patient encounter. Click the Screening Tools active text link on the left side navigation bar to open the Screening Tools pop-up template.

If you use the screening tools in the Website Screening Tools section, you must calculate the results and enter the score manually on the template. To generate a screening tool in the Website Screening

Tools section, click the Web button and then click the Print button or the Print icon.

Document Library

You can generate the screening tools results documents by clicking the Document Library active text link on the left side navigation bar to access the Document and Letters template. The Document and

Letters template allows you to generate documents for self-assessments, SLUMS and cognitive

assessment.

Quality Button on Screening Tools Template

Click the Quality button on the Screening Tools pop-up template to open the CQM - Screening Tools information pop-up template. The CQM - Screening Tools information pop-up template displays additional information about documenting CQM measures and the screening tools associated with each measure.

The intake staff workflow for an office visit involves documenting the patient encounter in the Intake and Histories templates. The information documented by the intake staff is used by the provider for reference and to proceed with the encounter.

Home Page - Dermatology Template

The Intake Staff workflow begins on the Home Page - Dermatology template. The Home Page -

Dermatology template allows you to view and add information about the patient.

To access the Home Page - Dermatology template:

1 Select Dermatology from the Specialty fields. 2 Select Office Visit from the Visit Type fields.

3 Select Home Page - Dermatology using the template module to open the Home Page -

Dermatology template.

The Home Page - Dermatology template contains the following panels, allowing you to view or change patient information:

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Skin Cancer Log panel Summary panel

Assessment History panel History Summary panel Allergies panel

Medications panel Vital Signs panel Orders panel

Communication panel

Home Page Sub-Navigational Links

The Home Page - Dermatology template includes the following sub-navigational links: Demographics

Call/Communication Provider Test Action Order Management Document Library

Demographics Sub-Navigational Link

The Demographics sub-navigational link displays the Patient Demographics template to document patient information such as contact information, address details, Primary Care Physician (PCP) details, insurance or pharmacy details, provider details, emergency contact details, and employment details.

Call/Communication Sub-Navigational Link

The Call/Communication sub-navigational link opens the Telephone Call template to record information gathered during a telephone conversion. The Telephone Call template can also be accessed by clicking the Telephone Call icon on the Patient Information Bar.

To enter details in the Telephone Call template: 1 Click the Call/Communication sub-navigational link.

The Telephone Call template displays.

The Specialty field displays the current specialty.

2 In the Communication panel, click the required communication category active text links to

display the corresponding pop-up templates.

a) Enter the call information, communication history, medication, and allergy details in the pop-up template.

b) Click Save & Close to return to the Telephone Call template. c) In the Display field, select a communication category.

The details documented in the selected category display in the Communications grid and in the

Medication and Allergies grids in the Medications and Allergies panel.

Note: Instead of using the active text links in the Communication section, you can double-click a

blank row in the Communications, Medication, and Allergies grid to enter the required information. In the Protocols panel, the data grid displays guidelines that exist for the current patient

documented in the Care Guidelines pop-up template. The grid displays any health maintenance or disease management testing that the patient is due for. When you select the Show due within check box, you can filter items so that only those items, which are due, within a specific time frame are displayed in the grid.

3 If applicable, click the Comments active text link at the top-right of the template to enter the

details of a conversation.

The Comments - Telephone pop-up template includes Provider comments and Nursing comments sections. When you click the Provider comments field, the Provider, Date and Time fields are automatically populated based on who is logged into the NextGen Ambulatory EHR, current encounter date, and current system time. Similarly, when you click the Nursing comments field, the Nurse, Date and Time fields are automatically populated.

The Telephone Call template includes the following buttons:

Button Action

Patient Contact Info Click to view patient's contact information and document patient's support relationships, and pharmacy details.

View/Scheduled Appointments

Click to add or view the patient's appointment with provider. Telephone Call

Summary

Click to view a comprehensive communication history.

Preview Document Click to generate a written summary of the telephone call details in runtime.

Provider

Communications

Click to document all of the details concerning a communication by the provider.

Offline Sends the telephone_communication document offline.

Provider Test Action Sub-Navigational Link

The Provider Test Action sub-navigational link opens the Provider Test Action template to document and/or view the patient's appointment, contact, and medication details along with any orders and the corresponding results. Providers can enter brief action details or notes and the tasks for future encounters, and manage all action items or tasks.

Orders Management Sub-Navigational Link

The Order Management sub-navigational link displays the Order Management template, which allows you to update the required order details.

To manage the order details:

1 Click the Order Management sub-navigational link.

The Order Management template displays.

2 Select any of the following options:

View of All Orders Diagnostic Lab Orders Office Services Procedures Referrals Other Orders

A list of orders associated with the selected category of order displays in the data grid.

The details of the selected order displays in the respective fields in the Manage selected order section.

4 If required, click the Status (step) field and select the appropriate status from the Select status of referral picklist.

5 Click the Action/comment field and select a value from the picklist.

6 Click Save to display the updated order details in the data grid in the Order status detail/action

section.

The following are the buttons available in the Order Management template:

Button Description

Dexa Scan Displays the Dexa scan results in the Dexa scan results section at the bottom of the template

Requisition Generates the requisition document displaying the details of the selected diagnosis. The Requisition button appears when you click the Diagnostic option.

Cosign Orders This Encounter

Displays the Cosign/Review Orders pop-up template to review or sign off the required orders.

Provider Communication

Displays the Provider Communication pop-up template to document details of provider's communication with the patient.

My Plan/Orders Displays the My Plan pop-up template to select a diagnosis and associate the required orders to it.

Save & Task Saves the updated order and displays the To Do pop-up template to send notification to the desired recipients. The Save & Task button appears when you select an order from the grid.

Document Library Sub-Navigational Link

The Document Library sub-navigational link displays the Documents and Letters template. The

Documents and Letters template includes active text links that generate the formatted letters and

assessment templates where you can enter the required data.

The Details button, available for some of the active text links, enables you to enter detailed

information. The information is included in the document generated from the corresponding active text links.

Risk Indicators (NextGen KBM 8.3 Dermatology)

The Risk Indicators for Dermatology are visible on all of the templates.

NOTE: Use the Derm Risk Indicators Config pop-up template to indicate the patient's current

conditions. If you want to indicate that the patient is at high risk for developing a certain condition, you can do so by going to the Care Guidelines pop-up template.

The Config icon displays the Derm Risk Factors Config dialog box to document risk indicators, including risk indicators for diabetes and other conditions.

In the Tobacco section, you can document the smoking status of the patient. The Tobacco Usage active text link enables you to document tobacco consumption details such as Tobacco type, usage per day, etc. You can also document smoking cessation efforts and passive smoke exposure.

If you click the Yes radio button for a risk indicator, a red circle with white exclamation mark displays next to the corresponding risk indicator icon.

If you click the No radio button for a risk indicator, a circle with backward slash displays next to the corresponding risk indicator icon.

If you click the Unknown radio button for a risk indicator,a circle with question mark displays next ot the corresponding risk indicator icon.

Intake Template

The intake staff use the Intake template to begin documenting a patient's chief complaint, vital signs, medications, allergies, orders and various other findings.

Intake Sub-navigational Links (NextGen KBM 8.3 Dermatology)

The Intake template includes the following sub-navigational links below the navigational tabs: Standing Orders Adult Immunizations Peds Immunizations My Plan Procedures Orders Management

Standing Orders

The Standing Orders active text link displays the Office Services dialog box. The Office Services dialog box is used to update or place orders and document details of diagnosis.

Adult Immunizations

The Adult Immunization active text link displays the Immunization - Adult template where you can add vaccine, medication, and allergies details of an adult patient.

To view the vaccination details:

The Immunization - Adult template displays.

2 In the Alert field, enter the alert information.

3 To view vaccination details, select an item in the data grid. To add the vaccination details:

1 In the Immunization - Adult template, click the New Order button.

The Create New Immunization Order dialog box displays.

2 Click the Search All button to search the desired vaccines.

The Search Vaccines dialog box displays.

3 Enter the search criteria and click Find.

Note: You can click the Search all vaccines radio button at the bottom of the Search Vaccines

dialog box to displays all the vaccines matching the search criteria.

The selected vaccine displays in the Assign Diagnosis to Selected Vaccines section.

5 Click the Vaccine Details tab at the bottom of the Create New Immunization Order dialog box. 6 Highlight a vaccine and enter its details in the required fields.

7 Click any of the following buttons: Save - Saves the vaccination details.

Save & Task - Saves the vaccination details and enables you to assign the task to the NextGen

Ambulatory EHR Work Group.

Save & Print - Saves the vaccination details and prints the VIS information. Save & Send - Saves the vaccination details and sends the details to registry.

The details display in the data grid in the Adult Immunization template.

Following are the buttons available at the top of the data grid in the Immunization - Adult template:

Button Action

Refresh Click to refresh immunization status data.

Print Click to print immunization summary.

Fax Click to fax the immunization summary. Historical Click to manually enter patient immunization.

Exclusions Click to review immunization exclusions for the selected group. Web Links Click to display a list of Web links for additional information about

immunization.

To document vaccine adverse event report:

1 In the Immunization - Adult template, click Add in the Vaccine Adverse Event Report section.

2 Enter data in the required fields.

3 Click OK to return to the Create New Immunization Order dialog box.

The Encounter date and Reaction date display in the Vaccine Adverse Event Report section. To add Medication and Allergies details, double-click the data grid in the Medication and Allergies sections to display Medication and Allergies modules respectively.

Peds Immunizations

The Peds Immunizations active text link displays the Immunization - Pediatric template where you can add the vaccine, medication, and allergies details of a pediatric patient.

The process for the Immunization - Pediatric template is the same as for adult patients.

My Plan

The My Plan active text link is used to select a diagnosis and the associated orders and then place the order.

To place an order for a diagnosis: 1 Click the My Plan active text link.

The My Plan dialog box displays.

2 In the Today's Assessment section, select a diagnosis.

OR

If the required diagnosis is not available in the data grid, click the Add Common Assessment active text link and select the desired diagnosis.

3 Select the desired orders available under the following labels:

Lab orders Diagnostics Office medications Office procedures Office labs Instructions Additional orders Follow-up/referral

If the required order is not available under a label, click the down arrow and select the desired order from the picklist.

4 Click the Place Order button. 5 Click Save & Close.

The Lab/Diagnostics/Radiology Order Module Processing active text link is used to select the vendor and submit the lab or radiology orders to the selected vendor.

Procedures

The Procedures active text link displays the Procedures template, which allows you to access several procedure templates associated with various systems.

To access a procedure template:

1 Click the Procedures active text links.

The Procedures template displays.

2 In the Pre-procedure care section, select the following check boxes after explaining the

pre-procedural care details to patient: Procedure/Risks were explained Questions were answered Consent was obtained

3 Click the active text link for the desired procedure, and the corresponding procedure dialog box

displays.

4 Enter the required details.

5 Click Save & Close to return to the Procedures template. 6 Click the Offline Proc Note button.

The procedure note document is generated.

Following are the buttons and active text link available in the Procedures template:

Field Description

Consent active text link Displays the Consent - Procedures dialog box to document the procedure and consent details.

Field Description

Consent button Generates the procedure consent document for preview.

You can print the document and take the signature of the person who consented the procedure.

Alerts button Displays the Add Alert dialog box to view and add the

alerts.

Patient Education button Displays the Patient Education Browser which contains a library of patient education documents.

Preview Proc Note button Displays the preview of the procedure note document.

Order Management

The Order Management active text link displays the Order Management template.

General Panel

The General panel displays whether the encounter is being documented for a new or established patient. The Established patient option is selected by default if the patient has previous encounters. You can manually change the selection if necessary. You can also select the person providing the patient information from the Historian list or select the top blank line to type a value in the field.

History of Present Illness Panel

The History of Present Illness panel on the *Intake template displays the top ten reasons for visit. The

Additional/Manage link found at the bottom of the list launches the Reason For Visit template with

To add reasons for visit:

1 In the History of Present Illness panel, select the Do not launch HPI check box. 2 Select the appropriate reasons for visit.

The selected reasons for visit display under the Chief Complaint column.

3 To document any details, click the Intake Comments active text link and enter your comments,

which display in the intake note document.

The Diagnostics button opens the Office Services pop-up template to enter various diagnostic tests and results.

The Show All button displays the HOPI Notes template.

Medications

The Medications panel is used to view the patient's current medications, enter additional prescriptions that the patient is taking, and reconcile the medications listed with what the patient is actually taking.

If there are no known medications for a patient, select the No medications check box above the grid. Select the Transitioning into care check box and/or the Summary of care received check box to document patient status.

To document the patient's medications:

1 If the patient is currently taking any medications, click the Add/Update button below the Medications grid or double-click within the Medications grid.

The Medication Module opens.

2 Click Prescribe New.

3 The Medication Search pop-up template opens.

4 Search for and select a medicine from the list and click Select.

5 Enter the Sig, Quantity, Refills, and Start date from the corresponding list.

6 If this medication had been prescribed elsewhere, select the Prescribed elsewhere check box. 7 Click Accept.

NOTE: If applicable, click the Comment active text link to launch the Medication Comment pop-up

template. This pop-up template should not be used to list medications that the patient is taking. If a medication has been prescribed elsewhere, enter as much information about the dosage and Sig as possible.

Medication Reconciliation for a Patient

Medication reconciliation is a review of patient adherence to prescribed medications. This may be performed in situations including, but not limited to, the following:

New patients

Periodically for established patients

After a hospitalization or emergency department visit After care by another provider

Whenever the provider thinks necessary

Medication reconciliation can be performed manually or electronically. To review the patient's medications and perform a medication reconciliation, click the Reconcile button. The Medication

Review pop-up template opens. The Medication Review panel contains two grids. The Medication List

grid displays a list of current medications that need to be reviewed for patient adherence. The Medication Review grid displays reviewed medications.

To review medications manually:

1 Select the Review – adherence check box above the Medication List grid.

2 In the Review – adherence picklist, select a patient adherence comment or select the top blank line

and manually type a comment.

3 To review all the medications in the Medication List, click the Review All – Taken As directed

button and the medications will move to the Medication Review grid below the Medication List.

NOTE: To review one medication at a time and select a different adherence for each, select one

row at a time in the Medication List. Each medication selected will move to the Medication Review grid. To move a medication from the Medication Review grid back to the Medication List, select the medication and click Remove.

4 To update the adherence of a medication in the Medication Review grid, do the following:

a) Select the medication in the grid.

b) Select the adherence you want in the Adherence picklist. c) Click Update.

5 In the Reconciliation Type panel, select the Manual reconciliation was completed check box. To review medications electronically:

1 Click the Electronic Reconciliation button.

2 On the Import tab, select the Surescripts medication history file. 3 Document who confirmed the medication list.

4 Perform a reconciliation between the medications in the EHR panel and the Surescripts® file

medications.

5 Click Confirm.

6 DUR interactions will display, if appropriate. 7 Click Close.

The Medication List in the Medication Review panel displays any updates or additions.

8 Document the patient adherence, if necessary.

After completing a manual or electronic medication review, select the Transitioning into care check box and/or the Summary of care received check box to document patient status, if applicable. Click

Save & Close. The Medications reconciled check box in the Medications panel should be selected.

Allergies

The Allergies panel is used to add and review the allergy information of a patient. If there are no known medication allergies for a patient, select the No allergies check box. If the allergies are listed in the grid for this patient but the patient does not have any new information to add, click the Reviewed,

no change option.

To document the patient's new allergy information:

1 If the patient reports a new allergy since the last visit, click Add.

2 Select the applicable check boxes and select their reaction from the corresponding picklist. 3 Click Save & Close.

4 Click the Allergies added today option if it is not automatically selected.

If the patient’s allergy is not displayed on the Adult Allergies pop-up template, close the pop-up template and double-click on any line (empty or not) in the Allergy grid to open the Allergy Module.

If applicable, click the Comment active text link to launch the Allergy Comments template. Patient allergies should not be manually entered in the Allergy Comments pop-up template. All allergies should be entered in the Allergy Module.

Note: If the Joint Commission standards have been enabled, allergy information must be documented

after entering whether the patient is new or established, along with the Visit type and Historian. After documenting allergies, continue entering information for the other panes.

Vital Signs Panel

The Vital Signs panel allows you to document the patient’s or patients' vital signs. You can also edit or remove an entry from the Vital Signs grid.

To record Vital Signs:

1 In the Vital Signs panel, click Add.

The Vital Signs [New Record] pop-up template displays.

The Measured Date, Time, the Measured By or user name and the Last Measured values

automatically display. The date and time can be manually changed but the user name cannot be modified.

2 For a female patient, click in the LMP field to enter the last menstrual period, if necessary. NOTE: The LMP field only displays for female patients.

3 Click in the Height (ft) field and use the numeric keypad on the right to enter numbers.

If the vital signs could not be taken, select the Unobtainable check box.

If the patient restricted the measurement of certain vital signs, select the Patient Refused check box and select a parameter from the Refused picklist.

NOTE: The Exclusions active text link opens the CQM Results pop-up template where you can

manage clinical quality measures exclusions for Meaningful Use. The Quality button opens the

Exclusions information pop-up template. The Non-MU Exclusions active text opens the Exclusions

pop-up template where you can document an exclusion reason not related to Meaningful Use by clicking a Reason option and selecting an item from the corresponding picklist.

4 Click the NEXT button below the numeric keypad or press Tab on your keyboard to move to the

next field.

5 To skip to the next field without entering information, click the NEXT button.

Note: If a height and weight are not entered on this template, a Body Mass Index (BMI) does not

calculate for the encounter. The template does not automatically search for a previous entry. Select the carried forward option to enter a previous height value in the Height field. Carrying forward a previously-entered height and entering a weight for today, causes a BMI status to display below the numeric keypad. If the BMI is out of the normal range (either too high or too low), a statement to this effect will display below the BMI.

The BMI Plan active text link opens the Health Promotion Plan pop-up template where you can document a Plan of Care if the patient's BMI is outside of normal parameters.

6 Click in the Pain Score field and select the appropriate value from the picklist for today’s visit. 7 Click the Calculate button to calculate the Body Surface Area (BSA), if needed. The calculated

BSA value displays in the BSA field.

After information has been entered in the Vital Signs [New Record] pop-up template and is saved and closed, the information displays in the Vital Signs grid. Only information documented today displays in the Vital Signs grid.

Health Promotion Plan Template

The Health Promotion Plan active text link in the Vital Signs panel opens the Health Promotion Plan pop-up template.

BMI plan of care (if BMI is outside normal parameters) Pain level and follow-up pain of care

Fall risk screening and falls care plan Functional status care plan

The Exclusions active text link on the Pain Management, Fall Risk, and Functional Status panels opens the CQM Results pop-up template where you can manage clinical quality measures exclusions.

To document a health promotion plan:

1 In the Vital Signs panel, click the Health Promotion Plan active text link.

The Health Promotion Plan pop-up template opens.

2 In the Health Promotion Plan panel:

The Patient's age and the calculated BMI values display.

a) In the Plan field, click the blue drop-down arrow and select a care plan. b) In the Diagnosis field, search for and select a diagnosis.

e) In the Physical activity field, select the physical activity suggested to the patient. f) In the Details field, enter the care plan.

g) In the Referrals fields, select the required values.

h) In the Details field, enter additional information on referral orders. i) Click Add.

The documented data displays in the Today's Diet, Physical Activity & Referral Orders grid. To update the data, select a record in the grid, make the applicable changes in the required fields, and click the Update button.

The updated record displays in the Today's Diet, Physical Activity & Referral Orders grid.

3 In the Pain Management panel:

a) Click the following fields and select an appropriate value: Pain Scale Method Location Onset Duration Quality

b) In the Follow-up plan of care field, enter the follow-up plan made by the provider.

4 In the Fall Risk panel:

a) Select the Yes or No option for the following questions: Falls in the last year?; if Yes, enter Number of falls. Did the fall(s) result in injury?; if Yes, enter Details. b) If applicable, enter comments in the Assisted devices field.

c) If an exercise program is provided, enter the details in the Balance, strength, and gait training field.

5 In the Functional Status panel:

a) Click the Screening Tool active text link. The Screening Tools pop-up template opens.

b) Click the required active text links in the Behavioral Health Assessments, Health Status

Assessments, and Self Assessments sections and enter data in the required fields to calculate

the score.

c) Click Save & Close.

The documented data displays in the Screening Tool grid.

You can click the Web buttons in the Website Screening Tools section to calculate the results and enter the score on the template manually.

Click the Screening instrument field and select an option.

Enter appropriate data in the Score, Severity/interpretation, Comments, and Major Depressive

Disorder (MDD) pre-treatment fields.

Click Add.

The data displays in the Screening Tool grid.

d) Click Save & Close to return to the Health Promotion Plan pop-up template. e) In the Follow-up plan of care field, enter comments for the follow-up plan.

The Task button is used to send the notification to the desired recipients.

6 Click Save & Close at the top of template to return to the Intake template.

After entering the systolic and diastolic blood pressure on the Vital Signs panel, you can document the care, screening, and follow-up for high blood pressure on the Health Promotion Plan template.

To document a plan for high blood pressure: 1 Select Hypertension Plan from the Plan list. 2 Click the Diagnosis field and select a diagnosis. 3 Click the Diet field to select an option from the list.

4 Click the Diet Details field to select an option from the Diet details pop-up template or enter a

comment manually.

5 Click the Physical activity field to select an option from the list. 6 Enter any comments manually in the Physical activity Details field.

7 Complete the Referrals section and enter any comments in the Referrals Details field. 8 Click the Lifestyle field to select an option from the list.

9 Enter any comments manually in the Lifestyle Details field.

10 Click Add to upload the data to the Today's Health Promotion Plan Orders grid. 11 Click Save & Close.

Quality Buttons

Quality buttons have been added to various sections of the Health Promotion Plan Template in NextGen KBM 8.3. The quality buttons launch pop-up templates containing information about documenting the associated CQM measure.

Health Promotion Plan Quality Buttons

Click the Quality button on the Health Promotion Plan panel. The dynamic information pop-up template opens based on the plan selected from the Plan list and the age of the patient.

Select BMI Plan from the Plan list and click the Quality button to open the CQM - BMI Plan -

Adults or CQM - BMI Plan - Peds information pop-up template, depending on the age of the

patient.

Select Depression Plan from the Plan list and click the Quality button to open the CQM -

Depression Plan information pop-up template.

Select Hypertension Plan from the Plan list and click the Quality button to open the CQM -

Hypertension Plan information pop-up template.

Pain Management Panel

Click the Quality button on the Pain Management panel to open the CQM - Pain Assessment and

Follow-Up information pop-up template.

Fall Risk Panel

Click the Quality button the Fall Risk panel to open the CQM - Falls Risk information pop-up template.

Functional Status Panel

Click the Quality button the Functional Status panel to open the CQM - Functional Status information pop-up template.

Orders Panel

The Orders panel includes the ability to process, manage, add, edit or remove an order. You can also access Immunization, Standing Orders, and the Task functionality. By clicking the Tuberculin Skin Test active text link, you can open the Tuberculin Skin Test template.

By default the View of All Orders active text is selected. The other options to view are Labs,

To document an order:

1 In the Orders panel, click Add to access the My Plan pop-up template.

2 Click the Assessments, My Plan, A/P Details, Labs, Diagnostics, Referrals, Office Procedures, and Review/Cosign Orders tabs to enter the required information.

NOTE: A Quality button has been added to the Diagnostics template. Click the Quality button to

open the CQM - Studies for Low Back Pain information pop-up template.

3 Click the Place Order button to process and include items in the Orders module. 4 Click Save & Close.

The Orders panel includes active text links to process lab and radiology orders, to open the Order

Management template, the Immunizations template, the Standing Orders in Office Services template

Point of Care Tests

In the Orders panel, the intake staff can document point of care office tests with the Office Services pop-up template.

To document an office test:

1 Click the Standing Orders active text link (or the Office Diagnostics button below physical exam

grid).

The Office Services pop-up template opens.

2 Click the Display category field and select an order set from the picklist. 3 In the Orders grid, highlight the row of the order you want to select.

4 Click the Add or Update Assessment button to access the Add or Update Assessments pop-up

template.

5 Select an assessment and an assessment code for the order and click Save & Close.

NOTE: The practice can pre-populate the assessment codes for Standing Orders so that the intake

staff does not have to.

6 Click the Diagnosis field and select a diagnosis for the order.

7 In the Results/Report section, click the Interpretation field and select the result of the diagnosis

from the picklist or click the Details active text link to document the result.

8 Select the Submit to Superbill check box. 9 Click the Place Order button.

After the order has been placed, the order is listed in the Today's Orders grid.

Review of Systems (NextGen KBM 8.3 Dermatology)

The Review of Systems panel enables you to document the findings after reviewing a list of systems. The list of systems can be customized by specialty or by provider.

To document the Review of Systems:

1 Click Derm - ROS in the blue pane to access the Dermatology - ROS pop-up template.

2 Click ROS Default field to access the Ngkbm Td Dbp Filter dialog box with default ROS

questions.

This list can be modified by practice and the content of each ROS default can also be modified by practice.

3 Click the Quick Load button in the right upper corner to open a list of saved default set names for this provider.

4 Click the Quick Save button.

5 Click the required options in the Review of Systems template. 6 Click Save & Close.

Note: If something is not correct, or additional questions need to be asked, a system may be

opened individually or the template where the information is entered can be re-opened.

7 Click the PHQ button to launch the Depression Screening - PHQ -2 pop-up template.

Intake Note Generation (Intake template)

The Generate Intake Note or Intake Note button at the bottom of the Intake and Histories templates is used to generate the Intake Note as the written summary of the encounter. It is recommended that staff create the document after all of the intake activities are complete. It is not necessary to generate the note twice during a visit.

Histories Template

The Histories template enables you to document a patient's social history, problem list, medical or surgical history, diagnostic study history, and family history.

Histories Sub-navigational Links (NextGen KBM 8.3 Dermatology)

The *Histories template includes the following sub-navigational links below the navigational tabs: Demographics

Order Management Document Library Chart Abstraction

Demographics

The Demographics active text link displays the Patient Demographics template to document patient information such as contact information, address details, Primary Care Physician (PCP) details, insurance or pharmacy details, provider details, emergency contact details, and employment details.

Order Management

For information on the Order Management sub-navigational link, see Intake Sub-navigational Links.

Document Library

The Document Library displays the Documents and Letters template. The Documents and Letters template includes active text links that will generate a pre-formatted document where information can be entered.

The Details button, available for some of the active text links, displays the corresponding dialog box to enter detailed information. The information is included in the generated pre-formatted document.

Chart Abstraction

The Chart Abstraction active text link displays the Chart Abstraction template. The Chart Abstraction template displays the allergy, medications, and histories information documented during the

encounter. You can add data or modify the existing data.

Skin Cancer History Log

Information can be added to the Skin Cancer History Log panel using the Pathology Results template. Click the Path Results active text in the upper left navigation pane.

The Pathology Results template opens. The Orders grid contains all pathology orders for the patient.

To enter pathology results:

1 Click on the appropriate row in the Orders grid for the pathology order to be resulted and

document the following: Accession #

Specimen ID Diagnosis

Additional Diagnosis Details Recommended Treatment

2 Select an option for Lesion has been treated and click on the Submit to Superbill button to submit

the pathology charge.

3 Click on the Add to Skin Ca Hx Log button to add the diagnosis to the Skin Cancer History Log. 4 Click on the Update Order button.

5 Complete the Follow up section. 6 Click Place Order.

7 Click Print Path Document to generate the pathology report document.

Problem List Panel

To meet Stage 2 Meaningful Use requirements, NextGen KBM 8.3 allows the user to electronically record, modify, and retrieve the patient's problem list over multiple patient encounters. By accessing