NextGen KBM Dermatology User Guide. Version 8.3

Transcription

1 NextGen KBM Dermatology User Guide Version 8.3

2 Copyright 2013 NextGen Healthcare Information Systems, LLC. All Rights Reserved. NextGen and NextPen are registered trademarks of QSI Management, LLC, an affiliate of NextGen Healthcare Information Systems, LLC. All other names and marks are the property of their respective owners. Notice: This document contains information that is confidential and proprietary to NextGen Healthcare and is intended for use solely by its authorized clients. This document may not be copied, reproduced, published, displayed, otherwise used, transmitted or distributed in any form by any means as a whole or in any part, nor may any of the information it contains be used or stored in any information retrieval system or media, translated into another language, or otherwise made available or used by anyone other than the authorized client to whom this document was originally delivered without the prior, written consent of NextGen Healthcare. By retaining or using this document, you represent that you are a client or an authorized representative of a client of NextGen Healthcare who is authorized to use this document under one or more agreements between you and NextGen Healthcare now in force, and that you will use this document and the information it contains solely as and to the extent those agreements permit. Any other use or distribution of the contents of this document, as a whole or in any part, is prohibited. Adobe and Acrobat are registered trademarks of Adobe Systems Incorporated in the United States and/or other countries. Microsoft, SQL Server, Windows, Windows Vista, Internet Explorer, Office, Word, Excel and Outlook are registered trademarks of Microsoft Corporation in the United States and/or other countries. Although a Microsoft trademark may appear in certain images within this document, Microsoft Corporation is not responsible for warranty support on the NextGen software products. 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. All other names and marks are the property of their respective owners. The examples contained within this publication are strictly present to show functionality of the software and are not intended to be guidelines for medical decisions or clinical approaches. Although NextGen Healthcare provides accurate documentation at the time of publication, it cannot guarantee going forward that Web site links to third-party vendors listed in this document do not become obsolete. NextGen Healthcare is not responsible for the contents of any such linked sites or any link contained in a link site, or any changes or updates to such sites. The inclusion of any link does not imply endorsement by NextGen Healthcare of the site and is solely being provided to you as a convenience. Use of any such linked Web site is at the user s own risk.

3 Although we have exercised great care in creating this publication, NextGen Healthcare Information Systems, LLC assumes no responsibility for errors or omissions that may appear in this publication and reserves the right to change this publication at any time without notice. Notice: The following are all registered trademarks or trademarks of NextGen Healthcare Information Systems, LLC: NextGen Ambulatory EHR NextGen Dashboard NextGen EHR Connect Insight Reporting NextGen HIE NextGen HQM NextGen KBM NextGen Mobile NextGen Patient Portal NextPen NextGen CHC Reporting Module NextGen Population Health NextGen Remote Patient Chart Synchronization NextGen Appointment Scheduling NextGen Document Management NextGen Practice Management NextGen Billing Services Management NextGen Optical Management NextGen Real Time Services The following terms may be used interchangeably throughout this document: NextGen Ambulatory EHR and NextGen EHR NextGen Practice Management and NextGen EPM NextGen Optical Management and NextGen Optik NextGen Document Management and NextGen ICS NextGen Patient Portal and NextMD NextGen Remote Patient Chart Synchronization and NextGen PatientSync NextGen Real Time Services and NextGen Real-time Transaction Server NextGen CHS and NextGen HIE

4 Document Revision History App Version Build Number Date Document Version Summary of Changes 8.3 NA 11/8/ General Release 8.3 NA 6/1/ Initial Release of Document 8.3 NA 05/09/ Initial Draft

5 NextGen KBM 8.3 Dermatology User Guide Contents Chapter 1 Introduction 9 Requirements... 9 Configuration and Setup Procedures 11 The Joint Commission Standards Configuration Reason for Visit Configuration Sub-Navigational Links General Office Visit Workflow 15 Patient Information Bar Active Text Links (NextGen KBM 8.3 Dermatology) Alerts Panel Controls Quality Buttons and CQM Information Pop-up Templates Care Guidelines Global Days Screening Tools and Document Library Intake Staff Workflow 29 Home Page - Dermatology Template Home Page Sub-Navigational Links Demographics Sub-Navigational Link Call/Communication Sub-Navigational Link Provider Test Action Sub-Navigational Link Orders Management Sub-Navigational Link Document Library Sub-Navigational Link Risk Indicators (NextGen KBM 8.3 Dermatology) Intake Template Intake Sub-navigational Links (NextGen KBM 8.3 Dermatology) General Panel History of Present Illness Panel Medications Medication Reconciliation for a Patient Allergies Vital Signs Panel Health Promotion Plan Template Orders Panel Point of Care Tests Review of Systems (NextGen KBM 8.3 Dermatology) /08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 5 of 116

6 Contents Intake Note Generation (Intake template) Histories Template Histories Sub-navigational Links (NextGen KBM 8.3 Dermatology) Skin Cancer History Log Problem List Panel Problem List Panel History Summary Panel Social History Tobacco Template Family History Diagnostic Studies History Review Intake Note Generation Patient Tracking Provider Workflow 75 Patient Tracking Home Page - Provider Review Panels on the Dermatology Home Page Template History Summary Panel on the Home Page Template Allergies Panel on the Home Page Template Medications Panel on the Home Page Template Vital Signs Panel on the Home Page Template Orders Panel on the Home Page Template Communication Panel on the Home Page Template Document SOAP (NextGen KBM 8.3 Dermatology) Compose Introduction Quick Note Reason for Visit on the SOAP Template (NextGen KBM 8.3 Dermatology) Review of Systems on the SOAP Template (NextGen KBM 8.3 Dermatology) Vital Signs on the SOAP Template Physical Exam Panel (NextGen KBM 8.3 Dermatology) Create Assessment/Plan (NextGen KBM 8.3 Dermatology) SOAP Link Icons Save Quick Note Generate Note Finalize Template Finalize Tab Sub-Navigational Links (Derm) Tobacco Cessation Sub-Navigational Link General Panel Today's Assessment Panel (NextGen 8.3 KBM Dermatology) Provider Sign Off Panel Evaluation and Management Coding Panel E & M Level Summary Panel History Details Evaluation and Management Guidelines Physical Exam Details Panel Multi System Physical Exam Details Panel Page 6 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

7 NextGen KBM 8.3 Dermatology User Guide 97 Single System Physical Exam Details Panel Dermatology Procedure Billing Panel Checkout Staff Workflow 97 Checkout Template (NextGen KBM 8.3 Dermatology) Today's Orders Panel Send Tasks Given to Patient/Verified Panel Patient Tracking - Check Out Generate Note Procedure Template and Skin Cancer History Grid 103 Using the Procedure Template and Skin Cancer History Grid Derm Quick HPI 105 Using the Derm Quick HPI New Codes for Dermatology Assessment 107 New Codes on Dermatology Common Assessment Excision Template 109 Using the Excision Template Biopsy Log 111 Using the Biopsy Log Mohs Templates 113 Using the Mohs Templates Index /08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 7 of 116

8 Contents This page is intentionally left blank. Page 8 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

9 NextGen KBM 8.3 Dermatology User Guide C HAPTER 1 Introduction 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 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 9 of 116

10 Chapter 1 Introduction This page is intentionally left blank. Page 10 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

11 NextGen KBM 8.3 Dermatology User Guide C HAPTER 2 Configuration and Setup Procedures 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 11 of 116

12 Chapter 2 Configuration and Setup Procedures 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. A list of system templates displays in the System tab. Page 12 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

13 NextGen KBM 8.3 Dermatology User Guide 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 sub-navigational links that appear beneath the tabs. If you click a subnavigational link, the corresponding pop-up template opens. The links can be customized by the following: 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 13 of 116

14 Chapter 2 Configuration and Setup Procedures 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. Page 14 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

15 NextGen KBM 8.3 Dermatology User Guide C HAPTER 3 General Office Visit Workflow 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: 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 15 of 116

16 Chapter 3 General Office Visit Workflow 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 , Telephone Call, To Do, and Patient Tracking icons, which allows you to send an , 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. Page 16 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

17 NextGen KBM 8.3 Dermatology User Guide 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 17 of 116

18 Chapter 3 General Office Visit Workflow 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, gynecologic history, pregnancy history, and safer sex information/contraception information. Page 18 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

19 NextGen KBM 8.3 Dermatology User Guide 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 19 of 116

20 Chapter 3 General Office Visit Workflow 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. Page 20 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

21 NextGen KBM 8.3 Dermatology User Guide 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 Bedridden 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 21 of 116

22 Chapter 3 General Office Visit Workflow 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 Expand All icon is used to open all of the panels at once and the Collapse All icon is used to close all of the panels in the template. Page 22 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

23 NextGen KBM 8.3 Dermatology User Guide 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. When you click the Quality button, the Patient Status information pop-up template opens. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 23 of 116

24 Chapter 3 General Office Visit Workflow 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. Page 24 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

25 NextGen KBM 8.3 Dermatology User Guide 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: 1 Click Global Days active text link to access the Global Days pop-up template. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 25 of 116

26 Chapter 3 General Office Visit Workflow 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. The assessments in the Interactive Screening Tools section automatically calculate the results. Page 26 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

27 NextGen KBM 8.3 Dermatology User Guide 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 27 of 116

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29 NextGen KBM 8.3 Dermatology User Guide C HAPTER 4 Intake Staff Workflow 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: 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 29 of 116

30 Chapter 4 Intake Staff Workflow 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. Page 30 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

31 Call/Communication Sub-Navigational Link NextGen KBM 8.3 Dermatology User Guide 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 popup 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 31 of 116

32 Chapter 4 Intake Staff Workflow 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 Patient Contact Info View/Scheduled Appointments Telephone Call Summary Preview Document Provider Communications Offline Action Click to view patient's contact information and document patient's support relationships, and pharmacy details. Click to add or view the patient's appointment with provider. Click to view a comprehensive communication history. Click to generate a written summary of the telephone call details in runtime. Click to document all of the details concerning a communication by the provider. 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. Page 32 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

33 NextGen KBM 8.3 Dermatology User Guide 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. 3 Select an order whose details have to be updated. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 33 of 116

34 Chapter 4 Intake Staff Workflow 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 Dexa Scan Requisition Cosign Orders This Encounter Provider Communication My Plan/Orders Save & Task Description Displays the Dexa scan results in the Dexa scan results section at the bottom of the template Generates the requisition document displaying the details of the selected diagnosis. The Requisition button appears when you click the Diagnostic option. Displays the Cosign/Review Orders pop-up template to review or sign off the required orders. Displays the Provider Communication pop-up template to document details of provider's communication with the patient. Displays the My Plan pop-up template to select a diagnosis and associate the required orders to it. 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. Page 34 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

35 NextGen KBM 8.3 Dermatology User Guide 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 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 35 of 116

36 Chapter 4 Intake Staff Workflow 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: 1 Click the Adult Immunization active text link. Page 36 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

37 NextGen KBM 8.3 Dermatology User Guide 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. 4 Select the desired vaccines from the search result and click OK. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 37 of 116

38 Chapter 4 Intake Staff Workflow 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 Refresh Print Fax Historical Exclusions Web Links Action Click to refresh immunization status data. Click to print immunization summary. Click to fax the immunization summary. Click to manually enter patient immunization. Click to review immunization exclusions for the selected group. 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. The Vaccine Adverse Event Report dialog box displays. Page 38 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

39 2 Enter data in the required fields. 3 Click OK to return to the Create New Immunization Order dialog box. NextGen KBM 8.3 Dermatology User Guide 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. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 39 of 116

40 Chapter 4 Intake Staff Workflow 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. Page 40 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

41 NextGen KBM 8.3 Dermatology User Guide 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 preprocedural 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 Consent active text link Description Displays the Consent - Procedures dialog box to document the procedure and consent details. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 41 of 116

42 Chapter 4 Intake Staff Workflow Field Consent button Alerts button Patient Education button Preview Proc Note button Description Generates the procedure consent document for preview. You can print the document and take the signature of the person who consented the procedure. Displays the Add Alert dialog box to view and add the alerts. Displays the Patient Education Browser which contains a library of patient education documents. 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 additional reasons. Page 42 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013

43 NextGen KBM 8.3 Dermatology User Guide 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. 8 Close the Medication Module. 11/08/2013 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Page 43 of 116

44 Chapter 4 Intake Staff Workflow 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. The Clinical Reconciliation Module opens. Page 44 of 116 Confidential Proprietary Information For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/08/2013