NextGen Training EHR Manual MEDICAL PROVIDER - PRENATAL For Coastal Health & Wellness Use Only. Rights Reserved.
Table Of Contents
O GETTING STARTED WITH EHR
A. How to Access, Login and Exit the NextGen Application Pg I. Accessing NextGen 1 II. Logging In 2 III. Logging Out/Closing the NextGen Application 4
B. Common NextGen EHR Elements I. Shortcuts 5 II. EHR Desktop 6 III. EHR Toolbar and Icons 7
C. Changing Your Password in EHR I. Changing your Password 8
D. How to Access Patient Charts in EHR I. Selecting the Location 9 II Selecting the Provider 9 III Patient Icon 10 IV Patient Information Bar 11 o Alerts 13 o OBGYN Details 14 o Sticky Notes 15 o Advance Directives 15 o Screening Summary 16 V History Icon 17 VI History Toolbar 17 o Patient History Tab 18 Encounter Icons 19 History Toolbar Icons 19 o Categories Tab 20
E. Workflow I. Accessing Workflow/Inbox 21 II Clinical Tasking 22 III Appointments 25
F. PAQ I. Accessing Provider Approval Queue (PAQ) 28 o Sign-Off 29 o Reject 30 o Reassign 31 o Chart 31 o Badges 31
Table Of Contents
O MEDICAL PROVIDER’S RESPONSIBILITY WITHIN EHR - PRENATAL
I. Review the PAQ (Provider Approval Queue) 32 II. Reviewing Patient Scanned Records 32 III. Accessing the Patient’s Encounter 33 IV. Panel Controls 34 V. Home Tab 34 o Risk Factors Config 34 o Contagion Risk 35 o OB Patient Header 36 o Chart Review 36 Reviewing Patient’s Chart 37 o Problem List 38 o Allergies 40 o Medications 40 o Orders 40 VI Intake Tab 41 o Reason for Visit 41 o Vital Signs 43 o Medications 44 . Adding New Medications 44 Using a formulary 45 o Electronically Sending or Printing Prescriptions 48 Electronically sending Prescriptions 48 . eRx/Fax 48 ePrescribing Controlled Substances 49 Download VIP Access APP on Mobile Phone 49 Send Controlled Prescription(s) 50 Printing Prescriptions 50 o Renewing a Medication 52 o Walgreen’s Contract 53 o Printing Education for Medications (Monographs) 53 o Documenting Sample, Authorization and Printing Spanish Labels for 54 Medications o Dosing Range 54 o Reconciling Medication 55 Reconciling Type Panel 56 Medication Review Panel 56 Updating the Adherence 57 o Allergies 57 . Adding Allergies 57 VII Gestational Age Tab 61 o Estimated Date 62 o 18-20 Week EDD Update 63 o General (UDS Reporting) 63 o Menstrual 64 o EDD Log 64
Table Of Contents
VIII Histories Tab 65 o Pregnancy 65 o Gravidity/Parity 67 o Since Last Menstrual Period 67 o Medical/Infection History 68 o Medical/Surgical/Interim 68 o General 69 o Family 70 o Social 71 . Social Determinants of Health 71 . Confidential History 73 o Genetic Screening/Teratology Counseling 73 IX Education Tab 74 o First Trimester Education 75 o Second Trimester Education 75 o Third Trimester Education 75 X Prenatal Detail Tab 75 o General 76 o OB Problem List 76 o Prenatal Visits 77 . OB Initial Physical Exam 77 o OB Lab Results 79 . Update/Review Lab Results 79 o Diagnostic Studies 80 . Record outside U/S 80 o Assessment/Plan 81 Diagnosis Code Lookup 82 o A/P Details 84 o Labs 85 Future Orders 86 Lab Only Order Form 87 Resulting an In-House Lab 87 o Referrals 92 o Office Procedures/Services 94 o Prenatal Record 96 o Immunizations 96 . Immunization Order Module Commands 97 . Chart Tab 97 . Recommendation 98 . Ordering an Immunization 99 . Deleting an Incorrect ordered Vaccine 102 . Mark as Exception 102 XI SOAP Tab 102 o Health Promotion Plan 103 Health Promotion Plan Panel 104 Pain Management Panel 105 Fall Risk Panel 105 Functional Status Panel 106 Table Of Contents
Screening Tool 106 . Screening Instruments 107 . Follow-up Plan of Care 107 XII Lab/X-Ray Results 107 XIII Procedures 109 XIV Document Library 110 XV Tobacco Cessation 112 XVI Finalize Office Visits 113 o Evaluation and Management Coding 113 o Generate Note 114 XVII Post Partum Tab 114 o General 114 o Review of Systems 116
O OTHER
A. ADDENDUM I. Accessing the Patient’s Encounter 118 II. Creating the Addendum Encounter 119 III Creating the Addendum Document 120
B. CHW COMMUNICATIONS I. Creating a Clinical Encounter 122 II. Selecting a Template 122 III Documenting within CHW Communications 123 Select a Category 124 Action details/Notes 124 IV Responding/Completing an Action Item 126 V. Clarification/Questions/Responses 127 VI Documenting without Needed Clarification 127 VII Completing an Action Item 128 VIII Other Orders 129
C. EDR ACCESS I. Accessing a Chart Through Appointments 130 II. Accessing the Patient’s Chart Through Patient Lookup 131 III Accessing a Chart 132 IV Chart Details 132 Both 132 History 132 Planned 132
Getting Started With NEXTGEN HOW TO ACCESS, LOGIN AND EXIT THE NEXTGEN APPLICATION`
I. ACCESSING NEXTGEN
1. Double left click on the NextGen 5 icon located on either the desktop or through RDS.
The NextGen Application Launcher will display.
2. Left click once on either Practice management (PM), Electronic Health Record (EHR), or Electronic Dental Record (EDR), depending on the database the user must access. The NextGen login window will display. The database name will display on the top banner based on which database the user is accessing.
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Getting Started With NEXTGEN HOW TO ACCESS, LOGIN AND EXIT THE NEXTGEN APPLICATION`
II. LOGGING IN 3. Left click once in the User field and enter your user name. (First time logging in, user name will be provided by IT)
4. Left click once in the Password field and enter your password (First time logging in, a password will be provided by IT)
5. Confirm the following fields display “Coastal Health & Wellness” Enterprise Practice
6. Left click once on Logon, the appropriate database desktop will display
PM
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Getting Started With NEXTGEN HOW TO ACCESS, LOGIN AND EXIT THE NEXTGEN APPLICATION` EHR
EDR
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Getting Started With NEXTGEN HOW TO ACCESS, LOGIN AND EXIT THE NEXTGEN APPLICATION`
III. LOGGING OUT/CLOSING THE NEXTGEN APPLICATION 7. Left click once on File, then Logout or Exit or the Down arrow in EDR, then Log Off or Exit
PM EHR EDR
A NextGen alert will display, A NextGen alert will display, The application closes Are you sure you want to Are you sure you want to Exit? logout of NextGen? All open Left click once on Yes screens will be closed. Left click once on Yes
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Getting Started With EHR COMMON NEXTGEN EHR ELEMENTS
In NextGen the Electronic Medical Records (EHR) is a computerized and secured manner to store electronic medical records created to have the ability to access in a timely manner. Users may also do some of the following:
Capture encounter (visit) information Submit superbills for services provided Generate standard and customized reports Generate customized letters to send to patients
I. SHORTCUT MENUS Mouse and Keyboard Throughout the EHR application there are short-cut menus. Users can access short-cut menus by right-clicking in the appropriate area. Users can usually complete a task by clicking on an icon from the toolbar menu located across each desktop or by right clicking on an item and selecting the option from the shortcut menu.
Mouse Usage: Use the left mouse button to select and click items. Use the right mouse button to display a shortcut menu of options.
Minimize:
Click on the Minimize button on the title bar of the active window. The program window will minimize to the Windows taskbar.
Maximize/Restore: On the Windows taskbar, click the Icon of the database to restore.
NextGen Application Launcher
EHR
On the EHR title bar, select the Maximize button to change the sizing of the user screen or restore to normal size
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Getting Started With EHR COMMON NEXTGEN EHR ELEMENTS II. DESKTOP
When you log into the EHR application, the EHR’s main window will display. All EHR functions are performed inside this window or desktop.
Title Bar: Displays NextGen’s Tool Bar: Contains a row of icons name and current patient’s Full Menu Bar: Contains several shortcut that allows access to functions and Name, DOB, Age, Sex, and menus. When you click on an item in the modules. Along with the current MRN menu bar, the short cut menu display location and Provider’s name
Practice name Status Bar: Displays the current status of EHR. Most common status “Ready”N Current Logged in User
Caps, Number, and Scroll Locks; Date
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Getting Started With EHR COMMON NEXTGEN EHR ELEMENTS III. TOOLBAR AND ICONS The Top toolbar is located directly under the NextGen EHR main menu. It consists of icon buttons, a location list and a provider list.
Use the toolbar to access various EHR functions quickly
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Getting Started With EHR CHANGING YOUR PASSWORD 1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
I. CHANGING YOUR PASSWORD IN EHR 3. Left click once on Admin on the menu bar
4. Left click once on User Password, the Change Nextgen Account Password screen displays
5. Left click once in the Old Password field and enter your current password
6. Left click once on the New Password field and enter your new password
7. Left click once on the Confirm New Password field and re-enter your new password
8. Left click once on OK.
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
I. SELECTING THE LOCATION Once the EHR database is logged in, the Select Location screen will display after a user accesses EHR
3. Left click once on the location in which patients are receiving services from o TC Coastal Health & Wellness (Texas City site) o Gal Coastal Health & Wellness (Galveston site)
. Lab users also have access to other locations for special unique projects
4. Left click once on OK, the location will display in the toolbar of the EHR
II. SELECTING THE PROVIDER The Select Provider screen displays O Even if you are not assigned a provider, select a resource, Nurse Only; Walk-In Provider. etc…
5. Left click once the provider in which services are being provided by, this includes documentation of any type of communication or encounter with a patient.
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
6. Left click once on OK, the provider name will display in the toolbar of the EHR
III. PATIENT ICON
7. Left click once on the Patient Icon located on the toolbar to access the patient lookup screen, to search for a patient’s chart. . Most users performing day to day tasks will mainly access patient charts through the Inbox icon. See “WorkFlow” documentation
8. Left click once in the Last (name) field and enter the person’s last name
9. Left click once in the Birth Date field and enter the person’s date of birth
10. Left click once on the Find button to display a search result of Matching Records of all persons with the same last name and date of birth NOTE: The less search criteria the user enters, the more person search result will display. If person is not listed based on search ALWAYS perform a double search by removing data from a field. Ex: Only enter a last name without a DOB or enter a DOB without a last name. Review each result in the matching records list and determine if the person is listed 10 For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents
Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
11. Left click once on the patient’s name to highlight the patient
12. Left lick once on Open to open the patient’s chart
IV. PATIENT INFORMATION BAR
The patient information bar displays: o Patient name, DOB, address, and contact information . additional phone numbers and email address can be accessed by clicking on contact
o Insurance/Payer Name (if patient has coverage) 11 For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents
Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR o Preferred Language o Patient Portal Enrollment o Alerts, Allergies, Problems, Diagnoses, Medications and Appointments, Badges/Hyperlink: Badges with numbers attached, indicate number of items. “?” indicates unknown . Hover over the total number next to the specific module and a preview list of the most recent items entered will display
. Double clicking on the Lab Results hyperlink opens the results grid tab of the lab orders module
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
. Left click once on the Orders button to open the Lab Order Module
o Alerts Users will be able to select an alert from a list of predefined alerts or create an alert using free text fields
Users will be able to enter specific comments, indicate to show alert button as red & bold and require acknowledgement from other providers or all users. Alerts requiring acknowledment will display when the chart is opened
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
Users (Provider or All users) will have to acknowledge an alert prior to preceeding
o Pharmacy name o Referring and rendering provider name (based on current encounter) o Hyperlinks: . OBGYN Details: enter female OB or GYN information
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
. Sticky Note: used for non-charting purposes. Carry forward until removed . Advance Directives: document living wills and directives if needed
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
. Screening Summary: Based on sex – document social, view screenings, such as, PAPs, Mammograms, etc.., and lead information
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
V. HISTORY ICON
Left click once on History icon to easily access the patient’s history toolbar, if a patient has not been selected the patient lookup screen will display first If a patient chart is opened, Patient icon will need to be used to look up a patient. The history icon will always open the history toolbar on the right side of the desktop, displaying patient’s history of encounters and templates.
VI. HISTORY TOOLBAR The History Toolbar is the most important tool for working with patients' files. The History Toolbar provides users access to virtually every single component of the patient’s medical record allowing easy access to the Modules within the EHR.
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
o PATIENT HISTORY TAB
Each folder displayed in the Contents window of the History Toolbar represents one Encounter. Folders preceded by a plus sign contain additional information, (e.g. a Template, a Document, a Procedure, etc...) To display all of the contents of a particular Encounter, left click once on the Expand button (+ plus sign) The icons within the folder represent the following: o Templates (blue chart icone) . Progress Note . Intake . Histories o Documents . Letters or addendums o Procedures . Charges associated to the visit o Problems . Diagnosis o Allergies o Medications o Orders . Lab and X-Ray orders
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR ENCOUNTER ICONS
Icon Allows you Create a new encounter. Allows you to create a new clinical encounter to New document telephone calls, etc… Lock an encounter. If accessible with rights, allows to lock an encounter, Lock no data can be added or removed from a template once an encounter has been locked. o A red lock means – an encounter was once locked but is now unlocked o A blue lock means the encounter is locked and only addendums can be added Search for a specific Allows you to search for a specific encounter by Search encounter. provider, location, diagnosis, and date range within the current patient
HISTORY TOOLBAR ICONS
Icon Opens Allows you Select Template dialog. Access to all available templates. Templates Generate a Document dialog. Access to all available documents. Documents Open Image File dialog. Open and modify images to illustrate patient's Images status. Procedure Summary window. View and/or add any charges to the selected Procedures patient. Problems Summary window. View and/or add any diagnosis to the selected Problems patient. Allergies Summary window. View and/or add any allergies to the selected Allergies patient. Medications Summary View and/or add all prescriptions for the selected Medications Window. patient. Labs Module Access the Lab Module Orders
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Getting Started with EHR HOW TO ACCESS PATIENT’S CHART IN EHR
O CATEGORIES TAB In this tab all “categorized” templates, documents, and scanned paper records will be stored. O Scanned documents are dated
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Getting Started with EHR WORKFLOW Definition: Centralized communication module where users can task, view appointments, access patient portal requests and providers can access the PAQ (provider approval queue.
1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
I. ACCESSING WORKFLOW/INBOX
3. Left click once on the Inbox icon to open the workflow/inbox screen . The workflow module will display multiple tabs. Tabs will be available based on the user’s functions. o Clinical Tasking o Appointments o Provider Approval Queue o Patient Portal
. A number behind each tab name indicates a total of items in the section
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Getting Started with EHR WORKFLOW A. CLINICAL TASKING
Access High Priority LIST OF TASKS tasks separately
Mrs. Test
DOB: 12 /14/81 (32 years)
(832) 555-5555 PHOTO
1234 Main Street MODULES Texas City, Tx
77590
The Clinical Tasking tab is similar to having a “To Do List” on a daily basis. The benefits of utilizing tasks in the workflow is to be able to quickly access the patient’s chart from a task, automate the “To Do List”, easily send and receive tasks. Users will be able to: o Keep track of all daily tasks o Access High Priority tasks separately o Send tasks to other users of phone calls, patent questions, etc.. o Accept or decline tasks assigned from other users REMEMBER – tasks are not part of the patient’s record. This is just a communication tool. Complete all pertinent patient information within the CHW Communications template. 1. Left click once on the task to activate and view details of the task . Preview details of the task; o From: o Sent date: o To: o Due date: o Priority: o Status: . Preview patient demographics (right of details) . Preview patient photo . Access to the following modules; o Alerts o Allergies o Diagnoses 22 For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents
Getting Started with EHR WORKFLOW o Medications 2. Accept the task to be able to complete, reply, or reassign the task, by selecting the Accept button (located at bottom of task)
3. Left click once on the “To: user name” section of the task to change the recipients if needed
o Provider will receive electronic refill requests here.
Mrs. Test
DOB: 12 /14/81 (32 years)
(832) 555-5555
1234 Main Street
Texas City, Tx 77590
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Getting Started with EHR WORKFLOW
. Approve refills directly from the clinical task
. Deny refills directly from the clinical task
o Terminated patients are identified in tasking, if a task is generated at the time the patient is terminated . CHW patients may be terminiated do to behavioral or financial reasons
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Getting Started with EHR WORKFLOW B. APPOINTMENTS
APPOINTMENT LIST
Todays Appt Details appts
PHOTO MODULES
The appointment window refreshes automatically every 1 minute. Users are able to change the date of the appointments by left clicking once on the calendar to view current, previous or future appointments. The appointments tab will default to the last provider(s) selected. Change the provider by left clicking once on the down arrow to the right of the provider name and use the check boxes to select.
View the status of a patient’s appointment (i.e. booked, kept, cancelled, waiting for provider, waiting on nurse, etc...) and what room the patient is in at a glance. The appointments are sorted and viewed by: o Cancelled appointments display with a line through it
Appt Time - Scheduled appointment time 25 For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents
Getting Started with EHR WORKFLOW Room - Exam room the patient may be assigned to. This is also a tracking tool. This can be updated by the provider, medical assistant, and/or nurse by selecting the Update button in the appointment details box. Add data in the Room field and commit changes to apply
Patient Name - The patient’s full name Subject – Appointment Type Reason – Reason for visit Status – Identify the appointment status This can be updated by the provider, medical assistant, and/or nurse by selecting the Update button in the appointment details box. Add data in the Status field and commit changes to apply
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Getting Started with EHR WORKFLOW Booked – an appointment that has been scheduled with this resource Kept – an appointment that has been checked in by front desk staff Waiting on Provider (status updated by user) Waiting on Nurse (status updated by user) Waiting on Medical Assistant (status updated by user) Lab/X-Ray (status updated by user) Resource – Provider or place (Lab/X-Ray) Wait Time – Elapsed time from check-in to check-out
Users can also view any past or future appointments by
o Left click once to highlight the patient’s appointment o Left click once on the History button located in the appointment details box
Promptly access the patient’s chart from the appointment details without having to perform a manual search
Left click once to highlight the patient’s appointment Left click once on the Chart button located in the appointment details box, chart will open
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NEXTGEN EHR Medical Provider PAQ Provider Approval Queue
General Information: The Provider Approval Queue (PAQ), gives users the ability to sign off on lab results, EHR generated documents and any scanned documents requiring a provider electronic signature. A provider can review, accept/reject, reassign and access charts from the PAQ. 1. Follow “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
3. Understand the “Workflow” process
I. ACCESSING PROVIDER APPROVAL QUEUE (PAQ) 4. Left click once on the PAQ icon on the toolbar, the Provider Approval Queue - Sign In screen displays.
5. Enter Nextgen user password . Left click once in the checkbox if user would like to be kept signed in on the current computer unless logged out
6. Left click once on Sign In, the PAQ displays
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NEXTGEN EHR Medical Provider PAQ Provider Approval Queue
The PAQ has several tabs and action buttons o For each individual item a description of the item, who created the item, and who last modified the item displays Pending Tab – view all items that are pending Rejected Tab – view all rejected items History Tab- view all PAQ items previously signed off o Sign-Off select the sign-off button to sign off a selected item . An item (order, document, etc…) is reviewed for sign off, the accepted item will drop off the pending list and store in history . Lab orders detail signed off documentation displays within the orders module
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NEXTGEN EHR Medical Provider PAQ Provider Approval Queue
o Reject Select this button to reject a selected item – only perform if a must – see reassigned. Ex: document received on a non- CHW patient . Orders cannot be rejected (see reassigned) . A rejection comment must be entered prior to rejecting . Left click once on Add . Left click once on reject, the item will move to the rejected tab If a document needs to be forward to another physician use the reassign button
o To Do – DO NOT USE. Users should only task within the CHW Communications template
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NEXTGEN EHR Medical Provider PAQ Provider Approval Queue o Reassign Select this button to reassign an item to another provider
Select the provider and the item will be sent to that provider. It will no longer display in your PAQ o Chart Select this button to access the patient’s chart
If action is needed – document within CHW Communications template prior to signing off o Ex: nurse to call patient with abnormal results o Badges
Hover over badges to access chart modules Left click once on the X to close out the PAQ
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
Purpose: The Medical Provider will be responsible for correctly reviewing and documenting patient data within the electronic health record.
1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
3. Understanding “Getting Started with EHR - How to Access Patient Charts in EHR”
4. Understanding the “Workflow” process
I. REVIEW THE PROVIDER APPROVED QUEUE (PAQ) See detailed document on PAQ
II. REVIEWING PATIENT’S SCANNED RECORDS 5. Left click once on the Categories tab, located within the History toolbar, to access any scanned paper records. Scanned documents are dated with the most recent document first.
6. Double click on the scanned date under the category to view the document, the document will display
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
Use the blue arrows to flip through the pages Use the rotating arrows to rotate the page if needed
III. ACCESSING THE PATIENT’S ENCOUNTER Once the chart has been opened through the workflow – appointments inbox
screen, left click once on the History icon to easily access the patient’s history toolbar
7. At this time users will ALWAYS perform a FOUR POINT CHECK, this is required at the start of every encounter workflow. It consists of selecting the Patient, Location, Provider, and the Encounter Date and Time. The four-point check insures that the information captured during the encounter is accurate for the selected patient. For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 33
NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
8. Left click once to highlight the encounter date, within the History Toolbar, to select the encounter to review or document patient information
IV. PANEL CONTROLS: Panel controls allow the user to expand and collapse all the panel and cycle icons rotate the panels through all positions. This helps decrease scrolling and manage panels to display only the most pertinent information.
A. Toggle: the down arrow allow users to expand all panels and the up arrow collapse all panels B. Cycle: the left arrow allow users to move the last panel to the top of the list and the right arrow moves the top panel to the bottom of the page
C. Individual arrows located at the end of the panels allow users to expand each panel individually
V. HOME TAB o RISK FACTORS CONFIG 9. Left click once on the gear button located in the upper hand corner of the home screen, a Risk Factors Config screen will display
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
o Tobacco o Smoking status o Tobacco use o Tobacco cessation discussed o Tobacco Usage o Hypertension o Diabetes o CAD 10. Left click once on Save and Close on the Risk Factor Config screen to update configurations o CONTAGION RISK
11. Left click once on the Contagion Risk to update Contagion Exposures
Add accordingly and select OK when done
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o OB Patient Header
Patient Header displays the following data: o Gravida, Para (G/P/T/P/A/L) –populates from data entered on the Histories template o Initial/Working EDD: - populates from data entered on the Gestational Age template o Working EGA: - populates from data entered on the Gestational Age template o Blood Type and RH: populates from Lab Orders pop-up template o Risk Level: Populates from the OB Risk Factors pop-up template
12. Left click once on the Risk Factors link here to complete the OB Risk Factor Template
o CHART SUMMARY Reviewing Patient’s Chart 13. Left click once on the “CHW OB Prenatal” template listed under the DOS encounter to begin a patient visit, the Home tab will display. For all office type visits, a template should have been created by the MA
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
14. Left click once on any of the following categories to view current and past documentation o Pregnancy History o OB Flowsheet Progress Notes o HPIs o Plans o Problem Lists o Family History o Past Medical/Surgical/Interim History o Allergies o Medications o Vitals o Referrals o Diagnostics o Labs o Clinical Guidelines For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 37
NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o PROBLEM LIST Review current listed problems
Select and update accordingly (also updated by provider through assessments/plan)
15. Left click once on the Add/Update button, a search screen will display
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
16. Left click once once in the search field and type in a description of a problem to document
17. Left click once on the Search button
18. Left click once on the appropriate problem and left click once on the Select button, attach to appropriate ICD10 code to add to the problem grid
19. Left click once in another fields to document pertinent information as needed
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
20. Left click once on the Add/Update button to add to the list of problems o ALLERGIES Review patient allergies
o MEDICATIONS Review patient medications
o ORDERS Review patient Lab, Diagnostics, Office Services, Immunization Today, Referrals; pending, completed orders
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NEXTGEN EHR Medical Provider
MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
21. Left click once on each of the categories to review
VI. INTAKE Tab Most of the data collected within the Intake Tab will be entered by the MA. Users will be able to review and update documentation of Reason for Visit and History of Illness (HPIs), Vital Signs, Medications, Allergies, complete pending orders and Review of Systems (ROS
o REASON FOR VISIT AND HPI (History of Presenting Illness) A list of the top HPIs are listed in blue. Add HPIs as needed per visit
22. Left click once on an HPI in the blue box or left click once on the Additional/Manage link to open a list of HPIs
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL
. Use the clear buttons to the right of any HPI entered in error, to remove from visit
23. Left click once on Save and Close to proceed, the HPIs selected will be listed in the Reason for Visit grid table
24. Left click once on each of the HPIs, one at a time, to complete each HPI individually
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25. Left click once on Save and Close for each HPI to update in the Reason for Visit grid
o VITAL SIGNS Mainly entered by MA or nurse. Review or update as needed using the Add button
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o MEDICATON . ADDING NEW MEDICATIONS
26. Left click once on the Medication Module , the Medication module will display
o All medications except in-house medications will display in the medication module. (unless manually added) o All new medication will be entered through the Prescribe New button o Medications are listed as an “Active” or “Inactive” status in the patient’s chart
27. Left click once on Prescribe New button to enter a new medication, the medication search screen displays
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28. Left click once in the Find field to enter the medication name, the medications with similar names will display. Select the appropriate medication
o USING A FORMULARY . Patients with coverage, such as, Medicaid, Medicare, and some private insurance will be eligible to prescribe from a medication formulary
29. Left click once on the ‘Use Formulary” field located at the top right of the medication search screen to access the medication formulary
. The display of the medication search will change
30. Left click once in the Find field to enter the medication name – search the medicaiton . Once the medication displays, based on the patient’s coverage, users will noticed a column which will indicate if the specific medicaiton is on the insurance’s preferred list or if the medication is considered Non-Formulary
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31. Left click once on the Select button to continue with prescribing the medicaiton.
32. Left click once on Select to add the medication to the patient’s chart, the medication will display in the Medication module
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o If any drug interactions occur – acknowledge the interaction and continue or cancel out and choose a different medication
33. Left click once on the following fields to complete writing the prescription Sig (directions on how to take the medication) o Based on the medication the system will display the most common sig, if there is no sig added by the system the provider will need to add it manually PRN – if needed Reason – if needed Quantity Units For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 47
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Refills Dispense as Written – if needed Start Date Stop Date – use this field for antibiotics or when a patient states they are no longer taking a medication or medication is ineffective.
Duration – will auto-populate a stop date Prescribed Elsewhere – use when meds were written by another facility Non- Clinical Notes to pharmacy Problem – link a diagnosis, if needed Provider Location
34. Left click once on Accept to add the medication as “Active” (the patient is currently taking this medication) o ELECTRONICALLY SENDING OR PRINTING PRESCRIPTIONS 35. Left click once on one or multiple medications to send out or print (use the shift key and select with the mouse to select multiple medications at one time)
Electronically sending prescriptions
36. Left click once on the Send button, most pharmacies are set to eRx, however some pharmacies may only accept faxes or users can force to fax, the Send Prescription screen will display, displaying the pharmacy
If no pharmacy is selected, left click once on the elipses button to search for a pharmacy.
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37. Left click once on OK to link pharmacy to patient’s chart
38. Left click once on the Force to Fax checkbox to change from eRx to fax
39. Left click once on the Send button – the Prescription will be sent as a fax A last audit column will display FAX as the format the prescription was sent out A las audit column will display eRx as the format the prescription was sent out ePrescribing Controlled Substances 40. CHW providers can send controlled substances through ePrescribing. A security code is required along with the user’s NextGen password to submit the controlled substance via surescript. The security code is obtained through an application “VIP Access.” Symantec Validation & ID Protection (VIP) Access, this is a free online security credential that can be downloaded to a mobile phone or directly to a desktop. VIP Access is used as an extra layer of identity protection. Follow the current workflow for entering medications into the medication module and select the prescription(s) to be sent. DOWNLOAD VIP ACCESS APP ON A MOBILE PHONE 41. Access the Play Store for android phones or App Store for iPhones
42. Search for VIP Access
43. Download the application. The app will then display on your phone
44. Contact a NextGen administrator to continue with the setup
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SEND CONTROLLED PRESCRIPTION(S) 45. Access the VIP Access app
46. Enter NextGen user password in the Password field in the Authentication Required area
47. Enter the token number from the VIP Access app in the Symantec VIP Token field
48. Left click once on the Authenticate button to verify the token
49. Left click once on the Send button
Printing prescriptions 50. Left click once on Print – printing option pop-up will display
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51. Left click once elipcises button to select a different printer (all workstations and pods are defaulted to print all other documents to the nearest printer). Prescriptions should only be printed on authorized security prescription paper.
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52. Choose the correct printer and select OK. The prescription printer should display in the Other: field O RX Printer
53. Left click once on Print – the prescription will now print to the appropriate printer o RENEWING A MEDICATION Renewing a medication is the same as refilling
54. Left click once on the Medication to highlight and activate
55. Left click once on the black down arrow of Renew, to display the pick-list.
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o Renew – Print RX – to print the prescription as it is written o Renew – Fax RX – to fax the prescription as it is written o Renew – Send eRX – to eRx the prescription as it is written o Renew – Edit RX – means to manually change the original prescription prior to eRx o Renew – means refill exactly how it was originally prescribed, if originally it was faxed it will be sent faxed and etc… o WALGREEN’S CONTRACT o Uninsured patients who are eligible for the 340B pharmacy services will automatically display a custom comment in the Medication Module when the prescription is accepted. o When a medication is accepted in the medication module one of the following descriptions will display in the Non-Clinical Notes to Pharmacy field of the prescription, if the patient is eligible for the 340B pharmacy services. . “[Pat Resp = 0 pct;]: – patient’s discount is 100% . “[Pat Resp = 20 pct;]” – patient’s discount is 80% . “[Pat Resp = 40 pct;]” – patient’s discount is 60% . “[Pat Resp = 60 pct;]” – patient’s discount is 40% . “[Pat Resp = 80 pct;]” – patient’s discount is 20% . “No discount” – patient has no discount and is responsible for 100% of charges . patients with coverage - no comment will display
o PRINTING EDUCATION FOR MEDICATIONS (MONOGRAPHS) o This step will normally be used when dispensing sample medication to a patient and a monograph needs to be given to the patient with the medication
56. Left click once on the down arrow of Resources
57. Left click on Monograph, the education material will display
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58. Left click on Print to print the material
O DOCUMENTING SAMPLE, PRIOR AUTHORIZATION AND PRINT SPANISH LABEL FOR A MEDICATION
59. Left click once on Addition Prescription Detail to display the Addition Prescription Detail tab located on the left hand side of the medication
o DOSING RANGE Allows the prescriber to view the minimum and max dose range according to age and weight
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O RECONCILING MEDICATION This step can be performed by the MA but, this is ultimately the providers responsibility to make sure all medications are correct in the patient’s chart
Medication Reconciliation – is a review of patient adherence to prescribed medications. This may be performed in situations including, but not limited to the following: o New patients o Periodically for established patients o After a hospitalization or emergency department visit o After care by another provider o Whenever the provider thinks necessary
60. Left click once on Reconcile button located on the bottom right of the Medication Module, the Medication Review pop-up template will display
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Reconciliation Type Panel 61. Left click once in the checkbox to select “Manual medication reconciliation completed with:” field
62. Left click once in on the blue down arrow to the right of the “Manual medication reconciliation completed with:” and select the appropriate selection Patient’s medication supply Patient’s personal medication list Summary of Care Document
63. Left click once in on the blue down arrow to the right of the “Medication list confirmed with:” field and select from the pick-list
Medication Review Panel 64. Left click once on the checkbox to the left of “Review”
65. Left click once on the blue drop down arrow of the adherence: field to select one of the following to document the reconciliation
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66. Left click once the Review All –Taken as Directed to document all medications listed as reviewed in one step Medications will display in the Medication Review grid, located at the bottom of the Medication Review pop-up template
67. Left click once the medication to update the status to “Verified”
Updating the Adherence: 68. Left click once on the medication in the Medication Review grid to highlight and make active, the medication will drop to the gray fields located below
69. Left click once on the blue down arrow of the Adherence field and select from the pick-list
70. Left click once on the Update button, the changes will display in the Medication Review grid
71. Left click Save & Close
O ALLERGIES o The allergy template is where staff will add, review, edit, and add comments regarding allergen history of the current patient o Users will always review allergies at each visit and document one of the following: o No Known allergies o Allergies reviewed, no change o New allergies added this encounter
o ADDING ALLERGIES
72. Left click once on the Allergy’s module , Allergy module will display
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73. Left click once on the magnifying glass icon to the right of the Allergy field: the Allergy Selection screen will display
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74. Left click once on the radio button in front of Contains to search for an allergy name, this will be the best way to search for an allergy
75. Left click once in the Description search field and enter the allergy name o Type in 3 characters to begin the search
76. Left click once on the allergy and left click once on Ok, the allergy will now display
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77. Left click once on magnifying glass icon to the left of Onset/Sym, to record the onset date the allergy occurred
78. Left click once on magnifying glass icon to the left of Resolved, to record the date the allergy was no longer an allergy
79. Left click once on the Add button of the Reactions field to document what reaction the patient experiences with the allergy. Up to 5 reactions can be added
80. Left click once on the radio button of the Severity to document the severity
81. Left click once on Add to Add Reaction window and OK to close out the Reaction screen o Follow the same steps to add multiple allergies to the patient’s chart
82. Left click once on Add of the Allergies screen to add the allergy to the Medication Allergy grid
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Allergies must be reviewed at each visit. Double left click in the allergy table to review and document allergies as “Reviewed”, the allergy module will display, If not already done by the medical assistant.
Left click once on Review, Last Reviewed By: User name and Date will display indicating allergies were reviewed.
VII. GESTATIONAL AGE TAB Most of the data collected within the Gestational Age tab will be entered by the MA
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Panels include: Estimated Date of Deliver 18-20 Week EDD update General (UDS Reporting) information Menstrual History EDD Log o Estimated Date of Delivery Panel
83. Document all pertinent clinical information: LMP Ultrasound dates Initial exam Conception IVF Conception Adjusted (provider) LMP . Definite . Approximate (month known) For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 62
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. Unknown o 18-20 Week EDD Update
84. Document all pertinent clinical information Quickening Fundal ht. at umbel Ultrasound Etc… o General (UDS Reporting) Panel
85. Document all of the following information: REQUIRED First Prenatal Visit Trimester o First o Second o Third First Prenatal Visit o Enter a date o Select: . Here . Elsewhere Multiple Gestation o Singleton o Twin o Triplets o Quadruplets o Other
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o Menstrual History Panel
86. Document all pertinent clinical information Menses – regular/irregular Frequency Menarche onset On oral contraception at conception Other contraception at conception Positive pregnancy test prior to care date
o EDD Log Registers all EDD information and modified EDD recorded
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VIII. HISTORIES Most of the data collected within the Histories tab will be entered by the MA
Panels include: Pregnancy History Gravidity/Party Since Last Menstrual Period Medical/Infection History Medical/Surgical/Interim General Family Social Genetic Screening/Teratology Counseling
o Pregnancy History Panel
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87. Left click once on the Add/Update button, the Pregnancy Outcome screen will display
88. Document all pertinent information: Pregnancy Entry Type Pregnancy # Delivery type: Etc… 89. Left click once on Add to Grid and all collected data will display in the Pregnancy history grid.
90. Left click once on Save & Close to close screen
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91. Document all pertinent clinical information: Full term Premature Abortion induced Abortion spontaneous Ectopic Living C-section SVD Multiple births o Since Last Menstrual Period Panel
92. Left click once in the checkboxes to select symptoms and medications since the pregnancy state or use the free text boxes to the left of the listed checkboxes: Abdominal cramps Breast tenderness Edema Febrile episode Headaches Nausea/vomiting Radiation exposure Rubella exposure Teratogen exposure Urinary complaints Vaginal discharge Vaginal bleeding Viral bleeding Medication Comments Symptoms since LMP
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o Medical/Infection History Panel
93. Left click once on any of the Neg or Pos radio button for each category. Details can be entered on any positive answers in the Medical/Surgical/Interim section below o Medical/Surgical/Interim Panel
94. Left click once on the Add button and the detailed Past Medical/Surgical screen will display
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95. Left click once in each checkbox to indicate history of Medical & Surgical
96. Left click once on Add to Grid, data will display in the Past Medical History Grid
97. Left click once on the Save & Close o General Panel
98. Left click once in the No or Yes radio buttons for each category
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o Family Panel
99. Left click once on the Add button to document family history
100. Left click once in each of the checkboxes to identify family history.
101. Left click once on Save to Grid, data collected will display in the family hostory grid
102. Left click once on Save & Closed
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o Social Panel
103. Left click once the Add button, the Social History screen will display – left click once on each category listed on the left hand side and complete each
104. Left click once on the Save & Close button, after all categories have been completed, information documented will display in the Social History Grid
o Social Determinants of Health– are the conditions in which people are born, grow, live, work and age - complete accordingly 105. Left click once the Social Determinants of Health hyperlink, the Social History screen will display – left click once on each category listed on the left hand side and complete each
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o Confidential History– to be completed accordingly 106. Left click once the Confidential History hyperlink, the Confidential History screen will display –left click once on each category listed on the left hand side and complete each
107. Left click once on the Save & Close button, after all categories have been completed, information documented will only display within this screen. The screen must be reopened to review o Genetic Screening/Teratology Counseling Panel
108. Left click once on the No or Yes radio button for each category For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 73
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109. Left click once in the checkbox to the right of each answer to indicate Mother(Patient), Father(baby’s) and or Relative (mother or father)
IX. EDUCATION
Panels include: First Trimester Education Second Trimester Education Third Trimester Education
o First Trimester Education Panel
Document education provided for each trimester of pregnancy
110. Left click once on the Add/Update button, the detailed trimester education screen will display for each section
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111. Left click once in the Check all education for 1st Trimester checkbox to select all checkboxes for the education screen Comment boxes to the right of the selections can also be used to enter free text data
112. Left click once on Save & Close, data will display in each education grid Repeat for 2nd and 3rd trimester education as well
X. PRENATAL DETAIL
Panel Include: General OB Problem List Prenatal Visits For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 75
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OB Lab Results Diagnostic Studies Assessment/Plan Orders o General Panel
113. Left click one in any of the white fields to enter data and or answer the No or Yes radio buttons o OB Problem List Panel
114. Left click once on the Add button to access the Problem/Detail list to document OB Problems
115. Left click once on the blue down arrow to access the list of problems
116. Left click once on a Problem
117. Left click once to identify Priority and add in additional information about the problem in the large white field
118. Left click once on the Save & Add New or Save & Close button to continue
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119. Left click once on the OB Initial Exam link to display the OB Initial Physical Exam screen and document findings
Document all pertinent information. 120. Left click once on either the Normal or Abnormal radio buttons or use the Default Normal checkbox
121. Left click once on Save & Close, on the OB Initial Physical Exam screen For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 77
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122. Left click once on the Add button of the Prenatal Visit Panel grid to display the OB_Flowsheet
Document all pertinent information.
123. Left click once on any of the radio buttons to select data
124. Left click once in the Progress Note field to document and free text data as needed
125. Left click once in the follow up fields to document follow up information
126. Left click once on Save and then click once on Close
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o OB Lab Results Panel All OB labs must be entered manually
127. Left click once on the Update/Review Lab Results hyperlink to manage OB labs
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128. Left click once in any of the fields to complete labs or ultrasounds completed
129. Left click once on OK to close screen and save data
o Diagnostic Studies
130. Left click once on the Add button, the Ob Diagnostics, to log any ultrasounds a patient has had
131. Left click once in the Type field and select the ultrasound
132. Left click once in the Diagnosis field and link a diagnosis to the order
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133. Left click once on Save o ASSESSMENT/PLAN ASSESSMENT Before orders can be placed an assessment must be added
134. Left click once on Assessments, the Add or Update Assessment screen will display
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135. Left click once on an assessment in the Billing Diagnosis History grid if the patient has a historical assessment code
DIAGNOSIS CODE LOOKUP 136. Left click once on the Diagnosis Code Lookup link to access a search window to add a new assessment not already in the patient chart
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137. Left click once in the search field and enter a description or code # Correct spelling must be used, but contains words can be used
138. Left click once on Search, a listing with the words containing in the search will display
139. Left click once on the assessment to be used to highlight and activate
140. Left click once on Select, the assessment will display in the add or update assesstment window in the ICD description field and in the ICD code field.
On the Add or Update Assessment window the following can also be added: . Impression For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 83
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. Differential dx description . Mark diagnosis as chronic . Add assessment to clinical problems. My tracked problems, my favorites
141. Left click once on Add/Update button to add the assessment to Today’s Assessments
Repeat for each assessment needed
O A/P DETAILS
The impression/comments section is used to document the provider’s details about the patient’s diagnosis. If additional details are needed for a differential diagnosis, the user can input that information in this section. Plan Details: This section is divided into two options. The user can choose the document plan information in the Patient Details and Provider Details section. The patient details will display on the Patient Plan document, but the provider details will not.
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142. Left click once on an assessment from Today’s Assessment list, the above fields will turn white and editable. Enter data accordingly Select additional assessments individually and update fields accordingly
O LABS Providers must order all in-house and sent out labs on this tab. This includes any future orders.
143. Left click once on the radio button to select the assessment (diagnosis) from the Today’s Assessments grid
144. Left click once in the checkbox Fasting to document if the patient is fasting for a specific test
145. Left click once in the checkbox in front of the lab test to order, the selected assessment will populate in the dx field, to the right of the lab test TEST NOT PART OF SCOPE: . Left click once on the field below Additional Lab Tests for any test not on the Governing Board approved fee schedule. These additional lab tests require prior approval from the Medical Director/designee. A pick-list will display.
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Type in the first couple of letters of the test description and select the correct test. Users may also consult with the lab supervisor.
146. Left click once in the Order Comments field to enter any additional comments if needed
147. Left click once on Place Order , the lab orders will populate in the Lab Orders table at the bottom of the screen.
FUTURE ORDERS (select future test prior to placing order) Providers can place future orders 148. Left click once in the Timeframe field or on this date field to state a specific timeframe or date
Example: Patient needs a weekly PT/INR test once a week for 3 weeks. The provider will select the date the patient needs to return in the Perform field, select the test with the diagnosis attached, and place order in between time periods. All orders will display in the Lab Orders table below
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LAB ONLY FORM
149. Left click once on the Lab Only Order Form button, (located within the Assessment/Plan grid – after labs are ordered and lab screen is closed) this form must go with the patient to the lab. Any lab (in-house) completed by the MA should be crossed out and initialed, this will inform lab staff not to perform the test.
o Resulting In-House Labs 150. Left click once on Lab/Radiology Order Processing (Intake and Checkout tabs) the GCP Order Module Proc IHR2 screen displays. Confirm or select the radio button for the In House Lab. The Vender should also be InHouse Lab
151. Confirm all in house tests ordered are listed in Today’s Orders grid
152. Left click once on the In House Lab test to highlight and make the test active to process
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153. Left click once on the down arrow to drop the lab tests in the Orders for Selected Vendor grid/table. Repeat for each inhouse labs
154. Left click once on the Process/Submit link, the lab will disappear from the Orders for Selected Vendor grid/table and transfer into the Orders Module
155. Left click once on Save and Close button on the GCP Order Module Proc IHR to close the pop up window and continue.
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156. Left click once on the Order Module from the patient history toolbar, the Order Module will display
157. Left click once on the Orders Summary tab to access All orders. The recently processed lab(s) will display first. Confirm all lab(s) were processed correctly and are all included in the same Order# if processed together. All labs processed and submitted in the Order Module will create a line item or an order including the following o Order # (PRO### system generated) o Encounter Date (date from encounter) o NextGen Status (Ordered, Assigned, Signed-Off) o Provider Name o Description
158. Left click once on the Order # of the lab(s) to highlight and make active to add results
159. Left click once on the down arrow of the blue Results row, this will expand the written results for review
160. Left click once on the New Results Entry tab within the Results tab
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161. Left click once in the Result field to enter the result based on the in hosue lab test. Once a lab is resulted, the results will automatically be sent to the provider’s PAQ (provider approval queue)
. Follow the following format to complete each In House Lab correctly Test Description Result Description Pregnancy Test Negative; Positive Hemoglobin A1c A number result only, such as, 8.3 Glucose (Finger Stick) A number result only, such as, 80 H. Pylori Negative; Positive Wet Mount Negative, Normal, Clue, increased WBCs, Trichomonas, Increased RBCs KOH Negative, Normal, Hyphae Rapid Strep Negative; Positive Rapid Mono Negative; Positive Microalbumin Normal, Abnormal, ALB – numerical value CRE – numerical value, A:C – numerical value Occult Blood (cards) 1St Date (use the Obs Date/Time to indicate the actual day the specimen was collected) 2nd Date (use the Obs Date/Time to indicate the actual day the specimen was collected) 3rd Date (use the Obs Date/Time to indicate the actual day the specimen was collected)
Urinalysis (dipstick) Color For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 90
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o Light yellow, Yellow, Dark yellow, Amber, Bloody Glucose o Negative, 100 mg/dl, 250 mg/dl, 500 mg/dl, 1000 mg/dl, 2000 mg/dl Bilirubin o Negative, Small, Moderate, Large Ketones o Negative, Trace, Small, Moderate, Large, Very large Specific Gravity o 1.000, 1.005, 1.010, 1.015, 1.020, 1.025, 1.030 Blood o Negative, Trace non-hem, Mod. Non-hem, Trace, Small, Moderate, Large pH o 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5 Protein o Negative, Trace, 30, 100, 300, 2000, or more Urobilinogen o Normal 0.2, 1 mg/dl, 2 mg/dl, 4 mg/dl, 8 mg/dl Nitrite o Negative, Positive Leukocytes o Negative, Trace, Small, Moderate Large 162. Left click in the Result Comment to enter additional information pertaining to the order
163. Left click once on the Save button, a document with patient results is sent to the ordering provider
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164. Left click once on the radio button for Specialty/specialist name/site
165. Left click once in the Specialty field to display the specialty pick-list, select the specialty
166. Left click once in the Diagnosis field to select a diagnosis to link to the referral
167. Left click once on the radio button for Evaluate and treat
168. Left click once in the Reason for referral field to enter the reason for referral in detail A time limit and timeframe can be entered as well
169. Left click once in the Clinical Information/Comments field and enter detailed information in reference to the referral 170. Left click once on Add , the select task recipients screen will display – task the Referrals department.
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171. Left click once on OK on the select task recipients screen – a task is sent to the referral clerk o This step is only done per patient not referral o Continue to add multiple referrals as needed o The ordered referral will display in the Referrals ordered this encounter table
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MEDICAL PROVIDER’S RESPONSIBILITIES WITHIN EHR - PRENATAL o OFFICE PROCEDURES/SERVICES These are in-house medication orders, supplies, etc…
172. Left click once on an assessment from Today’s Assessment to link to the order
173. Left click once on the down arrow next to the type of service needed Supplies Injections Medication Nebulizer Other o EKG o Patient Education
174. Left click once on the item to highlight and activate
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175. Left click once on OK, the order will display in the Office Service field
As needed complete the following fields . QTY – quantity when ordering multiple of the same order, such as, Rocephin – Rocephin comes in 250mg, if 1000mg is needed – change QTY to 4 . Seq . Strength . Dose . Units . Route . Side . Site
176. Left click once on Place Order , the order will display in the Office services ordered at this encounter table
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o Generate Prenatal Record Document (must be competed after all data is complete for the visit)
177. Left click once on the Prenatal Detail tab and access the Assessment/Plan panel
178. Left click once on the Prenatal Record button to generate a prenatal record document
o IMMUNIZATIONS To review and order immunizations, access immunizations within the Order Module
179. Left click once on the Immunizations tab to access the Immunization Module
o Vaccine questionnaire (Adult/Child/Teen) 180. Left click once on the Vaccine Questionnaire to complete, if needed
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o Immunization Order Module Commands
New order – Immunizations – order new immunizations Refresh – refreshed the immunization status data Print – print the immunization summary Historical – enter historical vaccines (mainly a nursing process) Exclusions – review immunization exclusions for the selected group Web Links – displays a list of Web links for additional information about the immunization o Chart Tab
Immunization o The name of the immunization Status o Current o Pending . Pending means the immunization has been ordered but not administered o Past Due . The past due date will display based on the recommended immunization schedule (see Recommendation Tab) Dose 1 o Pending means the immunization has been ordered but not administered o Will display the date the immunization was administered For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 97
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Dose 2 o Pending means the immunization has been ordered but not administered o Will display the date the immunization was administered
Dose 3 o Pending means the immunization has been ordered but not administered o Will display the date the immunization was administered
181. Left click once on an immunization to display details Dose # Vaccine Name CVX CPT code Status Date Ordered Admin Date/Time Administered By Amount Lot Expiration Date Manufacturer Route Site Notes Entered By Modified
o Recommendation Tab 182. Left click once on the Recommendation tab to view when an immunization is recommended to be administered
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Based on CDC guidelines
o Ordering an Immunization 183. Left click once on the down arrow to the right of New Order button and select Immunization Order, the Create New Immunization Order window will display
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184. Left click once in the check box to the left of the immunization(s) name to select an immunization to order. The Review Allergies window will display.
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185. Left click once on either the No or Yes radio buttons for the following allergies Neomycin Egg Latex Gelatin Existing Allergies will display in the grid below
186. Left click once on Save, to save the allergies selected the ordered immunizations will drop to the Selected Vaccines grid
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187. Left click once on the Save button to save and close the immunization window If any contraindications exist, the contraindication window will display for acknowledgment
o Deleting an incorrect ordered Vaccine 188. Left click once on the incorrect immunization to select and highlight
189. Left click once on the Delete Vaccine button to delete the incorrect immunization
o Mark as Exception If a particular vaccine is normally part of a schedule of vaccine, but the user does not want this administered, for the vaccine not to be counted against the schedule, highlight the vaccine and left click once in the checkbox to the left of the Mark as Exception selection
XI. SOAP TAB Users will be able to review and update documentation of Reason for Visit and History of Illness (HPIs), Review of Systems (ROS), Vital Signs, Physical Exam, Procedures, Assessments/Plans.
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o Health Promotion Plan
Panels include: Health Promotion Plan Pain Management Fall Risk Functional Status
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Health Promotion Plan Panel
190. Left click once on the blue down arrow located to the right of the Plan field Select from BMI Plan, Depression Plan, and Hypertension Plan
191. Left click in each of the following fields and either select from a pick list or enter free text For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 104
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Diagnosis Follow-up o Follow-up details Referrals o Specialty o Select Specialty o Timeframe o Details
192. Left click once on the Add button, the Health Promotion Plan will drop into the Today’s Health Promotion Plan Orders grid
Pain Management Panel
193. Left click once in each of the fields and complete
Fall Risk Panel
194. Left click once in each of the fields and complete
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Functional Status Panel
195. Left click once on the Screening Tool link to update the Screening Tool grid
Several Interactive Screening Tools are available: o Behavioral Health Assessments o Health Status Assessments o Self Assessments
196. Left click once on any of the blue links to access each screening tool and once the screening tool is complete, a detailed log will display in the Screening Tool grid
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. Screening Instruments: 197. Left click once on the blue down arrow to the right of the Screening instruments: to document other screening tools
198. Left click on the Add button and the Screening Tool will display in the grid
199. Left click once on Save & Close, to close the screening tool pop-up
. Follow-up Plan of Care
200. Left click once in the Follow-up plan of care to enter free text
XII. LABS/XRAY RESULTS o Labs
To review labs access the Order Module , the order module will default to the Results Tab, displaying results in a grid format
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Users can review each lab by date order
201. Left click once on the Orders Summary tab to access individual orders and to access the entire written result report, a default filter of All orders will display. Users can select from, Lab, Radiology, & Imm filters to be able to view specific results
202. Left click once on the the Labs filter to view only orders and results for abs, identified with
the lab icon , this includes in-house and outside labs
203. Identify the lab to review and Left click once on the lab order to highlight and make active
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204. Left click once on the down arrow of the blue Results row, this will expand the written results for review
A paper clip will indicate a scanned document is attached to the order
o Left click once on the paper clip icon attached to the individual order, the scanned document will display in the Results section of the order Repeat for each lab o Radiology Radiology results are written reports and are not housed in the Order Module, however, reviewing orders will help identify an ordered date to be able to find the radiology report 205. Left click once on the the Radiology filter to view only radiology orders, identified with the
radiology icon
206. Identifty the order/encounter date All radiology results are usually completed within 24 hours from an outside contracted radiologist. A new radiology encounter is created and the results is attached as a document to the radiology encounter
207. Left click once on the gchd_radiology_report to review the result of the radiology order
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XIII. PROCEDURES (when conducting procedures) A procedure consent must be complete prior to performing any procedures in clinic
Access the consent document by left clicking on the Consent button above the procedures module Complete Consent form and obtain signatures
208. Left click once on Procedures located at the bottom of the soap tab, the procedure pick-list will display
209. Double left click on the appropriate procedure Complete the appropriate template including selection of diagnosis codes and
Superbill
210. Left click once on Save and Close
XIV. DOCUMENT LIBRARY (Located at the bottom right of the SOAP tab or the navigation toolbar)
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211. Left click once on the Document Library to access the following documents for patients . Abnormal Lab Letter/Spanish . Generic . Jury Duty . Pain Contract . Patient Medication List . Patient Safety Contract . Prescription Prior Auth . School Medication . Work/School Excuse Brief or Detail . Well Child Documents . Patient Education
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XV. TOBACCO CESSATION (Located in the Histories tab or the Navigation toolbar)
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XVI. EM CODING (FINALIZE VISITS) Patient information is defaulted from previous tabs; the provider will make a medical decision, request a system calculated CPT code by calculate code button, submit the calculated CPT code, and generate a chart note (master_im)
o Evaluation and Management Coding 212. Left click once on one of the following radio button for the Medical Decision Making section . Straight forward . Low complexity . Moderate complexity . High complexity
213. Left click once on the Calculate Code button For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 113
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214. Left click once on Submit Code, if the user agrees with the calculated code To choose a separate code besides the code that was calculated code, users can left click once on the radio button to the left of the CPT code needed to be submitted
o Generate Note 215. Left click once on the Generate Note to generate a chart note (master_im)
XVII. POSTPARTUM TAB The postpartum tab will only display when the type of visit is OB – Postpartum
Panels include: Reason for Visit General Review of Systems Vital Signs Physical Exam Assessment/Plan
o General Panel
216. Left click once in the following radio buttons to select data for each of the following categories Delivery Type: o Vaginal Forceps o Vaginal vacuum For Coastal Health & Wellness use only. Rights Reserved. Return to table of contents 114
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o NSVD o Cesarean o VBAC Feeding method o Breast feeding o Bottle feeding o both Feeding complications (No or Yes) Newborn care visit completed (No or Yes) Baby enrolled in WIC program (No or Yes) Current Birth Control o Left click once in the fields and choose from a pick list
217. Left click once in one of the following grids to add an assessment: Diagnosis History – previously entered patient diagnosis Clinical Problems – previously entered patient chronic problems My favorites – once used and saved by user Add Common Assessment – grouped most common assessments pop-up template Diagnosis Code Lookup – allowed to add a description or diagnosis code for free search
218. Left click once an assessment to add to Today’s Assessments grid Add a s many as necessary
219. Left click once on an assessment in the Today’s Assessment grid if the assessment needs more information such as: Status – Acute, Chronic, Improved, etc… Side – bilateral, left, midline, right Site – arm, finger, leg, etc… Impression – free text description by user Differential Dx – Free text user description of diagnosis Mark diagnosis as chronic Add assessment to: Clinical problems; My tracked problems; My favorites
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220. Left click once on Add/Update button to update the assessment in the Today’s Assessment grid
221. Left click once on the Save & Close. The assessment and any added details will display in the Assessment/Plan panel
o REVIEW OF SYSTEMS – complete as needed
222. Left click once on a system and document all appropriate conditions per category or the General ROS female.
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223. Left click once on Save and Close, data documented will display in the Review of Systems grid
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NEXTGEN EHR Medical Providers ADDENDUMS Purpose: Ability to add documentation after a date of services in which occurred or needs clarification from the patient visit. Mostly performed after an encounter is locked.
1. Follow “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Getting Started with EHR - How to Access Patient Charts in EHR
3. Understand “Getting Started with EHR - Common NextGen EHR Elements”
I. ACCESSING THE PATIENT’S ENCOUNTER Once the chart has been opened through the workflow – appointments inbox
screen, left click once on the History icon to easily access the patient’s history toolbar
4. At this time you will ALWAYS perform a FOUR POINT CHECK, this is required at the start of every encounter workflow. It consists of selecting the Patient, Location, Provider, and the Encounter Date and Time. The four-point check insures that the information captured during the encounter is accurate for the selected patient.
5. Left click once to highlight the encounter date, within the History Toolbar, to select the encounter to link the document
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6. Left click once on File, from the menu bar
7. Left click once on New
8. Left click once on Addendum, a NextGen alert will display stating the addendum will be linked to the following encounter, encounter date, provider, and location name
9. Left click once on Yes, on the alert, if this is the encounter is correct, a second file folder with a paper clip will display below the encounter file folder
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10. Left click once on the Addendum encounter to highlight and make active o III. CREATING THE ADDENDUM DOCUMENT 11. Left click once on the Document Module to access the addendum document
12. Double left click on the document named - “Addendum”, a blank addendum document will generate
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13. Left click once in the addendum document to record information
14. Left click once on the ‘X’ to close and save the addendum document, an addendum document will display below the addendum encounter
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1. Complete “Getting Started with NextGen - How to Access, Login and Exit the NextGen Application” process
2. Understand “Getting Started with EHR - Common NextGen EHR Elements”
3. Understanding “Getting Started with EHR - How to Access Patient Charts in EHR”
4. Understanding the “Workflow” process
I. CREATING A CLINICAL ENCOUNTER 5. Left click once on the New button on the Patient History Toolbar, a clinical encounter will display –displaying a current date/time and linked to the Provider and Location indicated on the Toolbar
II. SELECTING A TEMPLATE 6. Left click once on the newly created clinical encounter to highlight, activate and attach the communications template
7. Left click once on the Templates Icon, the “Select Template” screen displays
CHW Communications CHW OB Prenatal CHW Progress Note
8. Left click once on CHW Communications and OK to open the template
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III. DOCUMENTING WITHIN CHW COMMUNICATIONS o Call Information (this step can be skipped if not a telephone call) 9. Left click once in the Contact Type field and select one of the following Incoming Call Incoming email Incoming fax Incoming voicemail Outgoing call
10. Left click once in the checkbox Patient if you spoke with the patient or Name field to document who you spoke with and their relationship to the patient
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12. Left click once in the “Other (this call only)” field if the patient needs to be called back to another number already not entered in the “Home” or “Work” field. o Select category 13. Left click once on either of the following radio buttons to identiy a category, this helps organize data Diagnostic Studies Referrals Other Reports Lab Orders Lab Results All orders Telephone Call o Action details/Notes 14. Left click once in the “Action details/Notes” field and in detail describe what action needs to be completed for the current patient
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16. Left click once on an individual user or workgroup
17. Left click once o the Add button to task recipients Keep in mind workgroups – example “Nurses” means more than one person can receive the task to complete Once the request is sent – scroll to the bottom to view the request
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18. Double left click on a line item needing clarification, the Provider Test Action Log will display
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20. Left click once on the Add button to the right of the clarification field, the clarification information will display on the same line item as the action item.
21. Left click once on the action line item to highlight and make active 22. Left click once Save and Task , the “Select Task Reciepent” screen displays, resend the task back to the sender o Documenting without needed clarification or completion This process can used to only document an action needing additional o Nurse calls patient – no answer – document no answer action and resend back to nurse workgroup, after certain attempts complete with statement of letter sent out
23. Left click once Save and Task , the “Select Task Reciepent” screen displays, resend the task back to the the workgroup, instead of original sender
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24. Double left click on a line item needing clarification, the Provider Test Action Log will display
25. Left click once on the Completed checkbox, a completion comments box will display
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27. Left click once Save and Close. The action item will display completed comments.
28. Left click once on the X to close out the “CHW Communications” template
3. V. OTHER ORDERS The call information section can be skipped, complete select category and action/details notes
29. Left click once on the Lab/Referral hyperlink, if a new lab/referral order needs to be completed, left click once on the Lab Master link to order new labs will display
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NEXTGEN EDR Medical Providers ACCESSING A CHART IN NEXTGEN DENTAL EDR
ACCESSING A CHART THROUGH APPOINTMENTS
1. Left click once on the appointments icon on the EDR toolbar, the Patient List dialog box displays
2. Left click once on the Select Resources button to display appointments per resource. Users can also filter by Date, Patient, Location and Provider. Patients are listed based on the filters selected. The list will display appointment time, last name, first name, event, appointment status (Booked or Kept), resource and location
3. Left click once on the patient’s name listed from appointments. Patient demographic displays at the bottom of the appointments grid. Double left click on the patient’s name to access the patient’s chart.
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II. ACCESSING THE PATIENT’S CHART THROUGH PATIENT LOOKUP
1. Left click once on the Patients icon on the EDR toolbar, the patient lookup pop up will display
Enter a patient name and DOB. Left click on the Find button to display a selection of patients based on the search criteria entered.
III. ACCESSING A CHART 2. Double click on the patient name to access the chart If a patient has a defaulted dental provider linked to the patient’s chart and the patient is check-in with another dentist an alert will display. The defaulted provider does not match the rendering provider (provider name) on the encounter. Would you like to set the default provider to (provider name)?
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o Always select NO
If alerts and allergies exist in the patient’s chart, the patient summary will display first
IV. CHART DETAILS Dental chart details are organized in 3 tabs, both, history, and planned Both: o Displays both completed and planned items History: o Displays completed items . These are documents and procedures completed on the patient Planned: o Displays planned items . These are future planned treatment plans
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COMPLETED ITEMS
PLANNED ITEMS
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