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Practical Implementation manual for NextGen KBM 8.0 in Pediatrics
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CHESI EHR NextGen MU Go-Live Pediatrics
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Table of Contents Table of Contents ........................................................................................................................................ 2
NextGen Basic Navigation ........................................................................................................................... 4
Setting Preferences ...................................................................................................................................12
Telephone Template .................................................................................................................................14
Generating a Telephone Message or Documenting Patient calls .....................................................14
Medication Management Template .................................................................................................16
Medical Question Template ..............................................................................................................17
Tasking Module (Responding to a Template tasked to you) ....................................................................18
Task List .............................................................................................................................................18
Accepting or Reassigning a Task .......................................................................................................19
Using the Medication Module and E-prescribingAccessing the Medication Module ...................24
Medication Action/Prescription Toolbar ................................................................................................26
Medication Details ...................................................................................................................................27
Additional Medication View Details ........................................................................................................27
Medication Searches ................................................................................................................................28
Searching for a Medication without the Formulary Browser .................................................................29
Other Prescription Options ......................................................................................................................32
Printing/ E-scribing Prescriptions ............................................................................................................33
Controlled Substances ......................................................................................................................33
Non-Controlled Substances .............................................................................................................33
Renewing Medications .............................................................................................................................35
Proper eRx flow using Formularies ..........................................................................................................36
Option #1: (recommended) Batch Eligibility ...........................................................................37
Option #2: (recommended) Check Eligibility .............................................................................37
Option #3 (recommended) Eligibility Checks When Creating a New Encounter in the
EMR (chart abstraction, telephone calls) .................................................................................38
Setting Preferences to see Formulary Browser for Providers (Optional) ..............................................40
Accessing the Formulary Browser (if the preferences are set) ...............................................................41
Searching for a Medication ...................................................................................................................41
Patient Eligibility Status ........................................................................................................................42
Medication Status .............................................................................................................................43
Formulary Notes ...................................................................................................................................43
Prescribing a Medication .....................................................................................................................44
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Non-Formulary Search .........................................................................................................................45
Using Mail Order Pharmacies ..................................................................................................................46
Using the Visit Templates and Clinic Workflow .....................................................................47
Peds MA/Nurse Workflow ........................................................................................................................48
Intake PEDS Template ..........................................................................................................................49
Reason for Visit – HPI Detail ................................................................................................................50
Entering Vitals ......................................................................................................................................51
Medication Reconciliation ...............................................................................................................52
Reviewing Allergies ..............................................................................................................................52
Standing Orders ....................................................................................................................................58
Entering Histories on the History Tab..................................................................................................58
Interim History .................................................................................................................................59
Medical and Surgical History ...........................................................................................................60
Family History ...................................................................................................................................61
Social History ....................................................................................................................................62
Peds Provider Workflow ..........................................................................................................................68
Summary tab ........................................................................................................................................69
Histories tab .........................................................................................................................................75
SOAP Tab ..............................................................................................................................................77
Finalize OV tab......................................................................................................................................84
Meeting Meaningful Use in Next Gen ......................................................................................................85
Vaccine Documentation ........................................................................................................................85
Vital Signs ..............................................................................................................................................87
All Orders Placed in the EHR .................................................................................................................88
Plan recorded in the EHR ......................................................................................................................88
Asthma ..................................................................................................................................................88
Tobacco Usage ......................................................................................................................................90
Patient Education ..................................................................................................................................92
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NextGen Basic Navigation
From the Desktop, select the NextGen icon
From the Application Launcher select EHR.
Enter your username and password.
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NextGen consists of 5 main sections. Title Bar: Displays Patient Name, Date of Birth, etc. Menu Bar: Displays links to various functions. Several important items are found in the
menu bar that will be discussed later. Tool Bar: Contains many shortcuts to basic navigation in the EMR application. Content Screen: Displays selected templates, modules, and documents. History Tool Bar: Displays Basic Chart contents.
Title Bar Menu Bar Tool Bar Content
Screen
History
Tool Bar
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Tool Bar
Closes information in the content screen
Patient look up
These icons access other user applications within NextGen
Default Provider and Location
Also known as the Workflow module, displays provider schedules and user’s tasks
Save, Clear and Delete information in the content screen
Opens the patient History Tool Bar to display chart information
Soft Log out. Allows you to exit EMR without losing your place in the documentation process. You will see the initial log in screen once you log back into the system, the patient information will still be open on the screen.
Navigating a Patient Chart
Select the “History” icon from the NextGen tool bar (this allows you to search and display the History Tool Bar
The Patient Look up dialog box will be displayed. Type the appropriate patient information in the designated fields then click “Find”. NOTE: Medical Record Number, Date of Birth or Social Security are the
safest search criteria.
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Double click the name for the patient’s chart you wish to open.
Patient History Tool Bar
Once the patient’s chart has been opened, review the History Toolbar on the
right side of the screen.
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History Tool Bar Tabs:
Patient Encounters: displays encounter dates and all associated templates, images, and
documents.
Patient Demographics: displays patient specific templates.
Categories: displays patient information by client-defined category
New Button- Creates a new encounter. Usually non-clinical services (telephone calls, faxes, voice
messages).
Lock Button- Places all information in encounter in a “Read Only” status.
Search Button- Opens a pop-up window that allows the user to
filter displayed patient encounter based on provider, location,
specialty, and/or diagnosis. Users can also filter based on a
date range.
Patient Encounters
Patient
Demographics Categories
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Encounters are like containers for patient information. Everything that is documented in the
patient chart must have an encounter.
The Encounter Display window contains the encounter date and all associated templates,
documents, images, and modules. Encounters lock after a certain time period that is defined by
the client. These encounters can only be unlocked by users with the appropriate security level.
Tic Tac Toe Menu
The Tic Tac Toe menu consists of 9 icons which open various Modules within Next Gen. There are
only 3 modules that we will be using during phase 1: Templates, Allergies and the Medications.
Templates, Documents and
Modules
Encounter Date
Locked Encounter
Templates
Allergies
Medications
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Templates: Templates are forms that ease the process of
collecting patient data that displays in the chart. The box
below will be displayed when you click the Templates icon.
You will then select a template to use depending on what
you are attempting to document.
Allergies: When you click on the Allergy module the following window will be displayed. You can
review, add, delete and resolve allergies from this module. More detailed information will be
provided in the allergy module
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Medication: After clicking on the Medication Module icon the following window will be displayed.
You can add, prescribe and refill medications from this module. See the Medication Manual for
detailed instructions on how to use this module.
To close Medication Module once you have completed your documentation, click the “Close” icon
on your NextGen Tool Bar. A message may display asking if you want to save your changes. Click
“Yes” to save your changes.
Once you are finished with the patient chart the only way to completely close ALL patient records
is to click “File” then “Close Patient”
Now all Patient records are closed because there is not a patient name displayed in the Title Bar.
Note: Patient name
in the Title Bar
ALL patient records
are closed
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Setting Preferences
Each user will need to set their preferences within the EHR system.
In the toolbar, go to Tools→Preferences.
Go to the Templates tab of the preference box.
The arrows in the middle will move items from side to side. If you select the double arrows it shifts all
items to the other side, this option is not recommended.
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Locate the desired templates in the left hand box and select the single arrow pointing to the right hand
box.
Change the Template Type to Demographics and locate the PHI_Log and the Patient templates and
utilize single arrow to right to move to preferred template box. You may select additional templates at
a later time.
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Telephone Template Generating a Telephone Message or Documenting Patient calls
1. Verify no patient record is open in
NextGen
2. Search for your patient using the “History” Icon
3. Search for the desired patient using any of the following criteria.
NOTE: Social Security and Date of Birth are the safest search criteria to use.
4. Create a New Encounter for today’s phone message
NOTE: An encounter is created for each telephone call received with the exception of:
Return calls in regards to a previously created encounter/phone template from the same
calendar day. New issues on the same day are new encounters.
5. Make sure your new Encounter is “highlighted” and click the “Template” button to access a new,
blank Telephone Template. Always use the Telephone Call template.
No patient info displayed
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6. Choose the type of Communication by clicking on one of the links below:
7. Each link will launch a pop-up that is specific for the type of communication selected. The most frequently utilized are the Medication Management and the Medical Question Templates.
1- Verify the
new encounter
is selected
4- Click OK 2- Click the
Templates Icon
3- Highlight the
Telephone Call
Template
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Medication Management Template
Choose or verify
patient pharmacy Indicate Contact Type
Document “spoke
with” info and Urgency
Select medication from list of
active meds or type in the name
of med requested
Checkboxes to indicate
actions taken on selected
medication.
Click Send and Close to
task refill request and
close the template
medication.
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Medical Question Template
8. When the Template is displayed fill in the appropriate information. Example: Patient Complaint
and Details then click “Send and Close” to forward the task to the appropriate resource.
9. Select the individual or group to task and move them into the Task Recipients list by clicking either
Add Users or Add Group(s) and click OK.
Indicate Contact Type
Document “spoke
with” info and Urgency
Document patient
question/concern and
detailed comments
Checkboxes to indicate actions
to be taken by the MA
Click Send and Close to
task refill request and
close the template
medication.
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Tasking Module (Responding to a Template tasked to you)
Start by opening your Work Flow/Inbox to view your tasks.
Task List
The Task List allows you an easy way to:
Keep track of all tasks to be completed for the day
Accept incoming tasks assigned to you
Reassign tasks assigned to you and accepted by you
The Task List Displays tasks:
Created by you sent to someone else:
Created and sent to yourself:
Sent to you created by someone else:
Sent to you and accepted:
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To ADD or REMOVE “Completed Tasks, Deleted Tasks or Tasks sent to Someone Else” click the
“Task Menu” and click the items you want to appear in your inbox. You can return to the task menu
and click the item again to remove it from your inbox.
Accepting or Reassigning a Task
To Accept or Reassign a Task Assigned to you:
Select the required task
Double-click to prompt the Task Details dialog
Click the Accept or Reassign button
NEVER select DECLINE
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If Reassigning the Task
Select the user or group to reassign the task to
4. To view the Communication Template associated with the accepted task, right click on the
message line in the inbox and select “Open Patient’s Template”
This will take you directly to the Communication Template attached to the task and open the relevant
Patients chart-To see the patient’s history information you may need to click the “History” button
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5. The selected communication then displays. Example: Medical Question
6. When the Template is displayed, fill in the information required to respond to the message.
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7. If you need to task the template again for completion or follow up, click the “Send and Close”
“Teply and Close” or the “Save and Close” button and select the appropriate resource. The process
is the same as previously documented.
8. If you are the last person to touch the task (no other follow up is required by any other user) Select
the Complete radio button and click “Save and Close”
9. Open the History toolbar and select the Telephone Template then
10. Click the Preview Document button on the lower left side of the template to generate the
documentation.
11. Click “file” “Close Patient” to close the active patient and return to the primary EMR desktop or to
your inbox.
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12. Return to Your “Inbox”
13. Mark the Task associated with the Template “Complete” to remove it from your Workflow by
checking the box next to the “clipboard” icon.
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Using the Medication Module
and E-prescribing
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Accessing the Medication Module Medication Module can be accessed in EMR by either clicking on the ‘Medications’ button on the
bottom right corner in the ‘tic-tac-toe’
…or by selecting a medication entry from the ‘Encounter History’ window.
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Medication Action/Prescription Toolbar
Users will perform specific actions regarding patient medications such as renew, inactivate or
interaction checks from the medication action toolbar. It also provides users the ability to prescribe
new medication and launch the medication search window. By selecting the arrow located to the left
of the medication action icons you will see a drop down list of related actions displayed.
The table below lists the functions available in the Medication Action/Prescription toolbar:
Function Description
Prescribe New The ability to prescribe new medication
Launches the medication search window
The ability to add historical medications (prescribed elsewhere)
Print The ability to print multiple medications using either the control key or the shift
key
Erx The ability to Erx (if enrolled in Surescripts)
Renew The ability to print Rx
The ability to Erx (if enrolled in Surescripts)
The ability to edit Rx
The ability to renew Rx
Stop Mark Ineffective to alert doctor if medication is prescribed again
Stop requires stop date to stop prescription
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Education Opens medication monograph window. Provides information about the selected
medication. This information can be printed
Dose range Opens the dosing range window. Provides the minimum and maximum dosage
for the selected medication based on patient criteria.
Delete Provides the ability to delete a medication. The following criteria must be
established:
User must have permission to delete
The patient encounter must not be locked
Medication Details
Users can view details of the current medication viewed by performing one of the following actions:
Highlight medication in Current Medication View window to view Details of currently selected
Medication
Highlight medication you want to and the detail will display in Prescribe Medication window below.
Additional Medication View Details
The medication module allows users to view additional medication details. The Full History, Dispense
History, as well as the DUR History are available as additional view options in the medication view
window.
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Full History View
The full history medication view provides a comprehensive view of a selected medication. It gives
users the ability to see all rows of medication history if needed. Stopped medication will appear in full
history view as inactive. Users can view medication full history by right clicking the selected
medication in the medication history window and selecting full history.
Dispense History View
The Medications Dispense History View provides a comprehensive view of all information related to
dispensing the selected medication.
Medication History View
The Medications DUR history view provides a comprehensive view of all available medication
interaction information. This information includes a display of acknowledgement reasons.
Medication Searches
A medication search is done by performing the following steps:
Logon to NextGen® EMR
Select a desired patient
Open the history tool bar
Select the medications module
The medication module displays
Click either the medication search icon or the prescribe new button
Or click the prescribe new button
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Searching for a Medication without the Formulary Browser
The medication module provides several options for prescribing medications including:
Provider-Defined Favorites Lists
Traditional Search
Search by Class
Prescription Renewal
Non-Formulary Patients: (once the alert has been cleared by clicking OK)
Users can search using the following options: o Keying the medication directly into the medications field o Class- this specifies a medication class to search in, for example, antibiotics, beta
blockers or anticoagulants o Filter- this specifies a medication type. The types available are:
Brand
Generic
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Or
Select the desired medication from the list of all medications or the FAVORITES TAB(s)
Double click the desired medication
The desired medication appears in the lower portion of the med module window
Click Select or double click desired medication
Fill in pertinent information (Quantity, Refills, Stop Date, etc.) and click Accept
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Formulary Patients:
Select the Use Formulary option in the upper right corner of the Search window.
The search is dynamic, begin to type the name of the drug and select it. The formulary detail will appear:
Once the medication is selected off the formulary list it will drop into the grid for completion.
**Prescribing from this point is same for FORMULARY and NON-FORMULARY patients:
Double click the desired medication from the grid
The desired medication appears in the lower portion of the med module window
Fill in pertinent info (Quantity, Refills, Stop Date, etc.) and click Accept
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Other Prescription Options
Users can modify other prescription options by selecting the appropriate checkbox in the prescriptions window. Refer to the list below for option descriptions.
Dispense as written – The medication should be filled as prescribed – Brand Name
Prescribed Elsewhere – Identifies where the medication was prescribed if not at the practice
PRN- Take as needed. A Reason field is provided with pick list
Additional Prescription Detail- This link displays a window (seen below) that allows the user to print prescriptions in Spanish, mark the medication as a sample, limit renewals, and/or record Prior Authorization information.
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Printing/ E-scribing Prescriptions
Once a prescription has been added, saved, and shows as ‘Active’ in the Medication window it can be printed to security paper or e-scribed and sent electronically directly to the pharmacy (if the pharmacy participates in Surescripts)
Controlled Substances
Users must print controlled substances on paper rather than sending electronically. To print a prescription, click on the ‘Print’ button on the medication toolbar and be sure that the proper printer has been selected. NOTE: If a medication printer has not been installed at your location, enter the medication in the Med Module, as it is the medication record, but use existing prescription pads
When printing medications, the user has the ability to print only the selected medication or all medications that have been prescribed during that encounter.
Non-Controlled Substances
Providers must be enrolled with Surescripts prior to E-scribing. See your NextGen Administrator if you are unsure of whether you have been properly enrolled.
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Prescriptions other than controlled substances should be sent electronically. If the selected medication is a controlled substance, the Erx button will be disabled.
Highlight the medication to be E-scribed and click the Erx button. The user will be prompted with the ‘Send Electronic Prescription window.
If the pharmacy is blank, or the default pharmacy is not correct, click the ellipses button to search for the correct pharmacy. Only those pharmacies that have been enrolled to accept Surescripts will be listed. Click the send button to submit the prescription electronically.
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Renewing Medications
Highlight the medication to be renewed and click the Renew button.
Renewals may be limited if the medication is inactive, number of renewals were limited; the original medication was prescribed elsewhere, etc.
Note: The medication renewed is changed to Inactive with a stop date of the current day and a new medication entry is added as Active with a current start date.
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Medications must be renewed into a current encounter. If one does not exist it will ask if the user wants to create one.
Acknowledge any alerts before proceeding. EACH ONE must be highlighted and acknowledged.
Proper eRx flow using Formularies
Eligibility request to SureScripts/RXHub
View plan formulary information
Send retail or mail order eRX
Receive retail refills (optional)
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Eligibility Checks
Eligibility for each patient is checked only once in a 24 hour period. Therefore, if a batch eligibility check is run in the morning for all of the patients with appointment and the medication module is opened a little later, it will automatically check to see when the last eligibility check was performed. Only if it has been greater than 24 hours since the last eligibility check will it send the request for eligibility to the RxHub.
Eligibility Checks via the Workflow Appointment List
Eligibility checks performed through the Workflow window are considered to be "On Demand." You can either check eligibility for all patients (batch) or individual patients.
Option #1: (recommended) Batch Eligibility
This method checks the eligibility for all patients that have appointments. Eligibility checks performed through the workflow window are considered to be "On Demand." Nextgen recommends running this check 1-2 times per day max. This can affect performance.
To use this method, open the Inbox, click the Appointment button and select Batch Eligibility.
Option #2: (recommended) Check Eligibility
This method checks the eligibility of a specific patient that has an appointment and can be used for add-ons.
To use this method, right-click a patient in the Appointment List and select Check Eligibility.
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Option #3 (recommended) Eligibility Checks When Creating a New Encounter
in the EMR (chart abstraction, telephone calls)
This method of eligibility performs a check automatically when you create a new Encounter for a patient in the EMR. This method checks the eligibility of that patient only
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What happens if eligibility check is not completed?
Providers can see the status of the eligibility check in the upper-right corner of the medication module
If eligibility has not been checked the Provider will receive the following message when attempting to dispense medications.
Select ‘Yes’ to run the
eligibility check
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Setting Preferences to see Formulary Browser for Providers
(Optional)
The Formulary tab of the NextGen EMR Preferences allows you to change preferences for the InfoScan Formulary Browser. (Tools- Preferences- Formularies)
Each Provider must set these preferences if they want to use the Formulary search by default. Access the formulary browser from the default browser by selecting “Use Formulary”.
Check the following in the
screenshot
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Accessing the Formulary Browser (if the preferences are set)
To access the Formulary Browser:
1 Select an Encounter and then click the Medications Module icon on the History
2
Toolbar.
The Medications window displays.
Click the New to open the Formulary Browser.
3 You can now search and prescribe medications using the formulary browser
Searching for a Medication
To search for a Medication with the Formulary Browser:
1 Access the Formulary Browser.
2 Verify that the Use Formulary check box is selected and that “MEDCO HEALTH SOLUTIONS” appears as the Formulary Provider.
3 Enter the name of the medication and click Search.
If you are unsure of the spelling, you can enter a partial name, as well as use a percent sign (%) as a wildcard.
The Formulary Browser displays the results of the search.
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If you entered the full medication name, available dosages and forms, medication status, and any formulary notes (if available) display.
If you entered a partial name or used a wildcard, expand the medication folder to view the specifics.
Patient Eligibility Status
When you search for a medication using the RxHub Formulary Browser, the patient eligibility status appears below the Formulary provider drop-down list. The status window indicates one of the following:
ƒ The patient is eligible
ƒ The patient is not eligible
ƒ No eligibility status is available
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Medication Status
Each Formulary assigns a specific status to each medication. The InfoScan Formulary Browser displays the pertinent status for each of the available medications. The following is the list of definitions used in Formularies:
Status
Definition Preferred This drug is favorable over all other drugs in the same therapeutic
category.
Approved This drug is authorized for reimbursement for the pertinent payer.
Prior Authorization
Reimbursement will be allowed only when the claim has been submitted to the payer by a physician for review prior to the issuance of a prescription.
Non Formulary Specified by the payer as not on the Formulary or on the Formulary at a higher co-pay level. This may or may not be reimbursable.
Not Reimbursed The payer does not pay for this drug. The patient will be required to pay for the medication if she or she chooses to do so.
Formulary Notes
Any information specific to the Payer that you should be aware of in order to properly write or fill a prescription according to that plan’s policies is included in Formulary Notes.
Notes are categorized as “Restriction” or “Advisory.” Restriction Notes are important messages from the Payer that restrict the use of a drug. Advisory Notes are informational messages.
Notes are attached on a drug-by-drug basis. Any given drug can have numerous notes
attached to it. If available, you can view Formulary Notes by right-clicking the Note icon.
Prescribing a Medication
To prescribe a Medication using the Formulary Browser:
1 Open the Formulary Browser.
2 Search for the medication to prescribe.
3 Double-click the desired medication, dosage and form.
If enabled, the system performs a Drug Interaction check, in which case, a warning dialog displays when an interaction with another prescribed drug or known allergy occurs
The medication now appears in a list of the patient's prescribe medications.
4 Complete the prescription by entering Stop Date, Quantity, etc.
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Non-Formulary Search
If needed, you can search for a medication using the generic search engine without disabling the Formulary Browser.
To perform a Generic Search:
1 Open the Formulary Browser.
2 Clear the Use Formulary box.
The Formulary Browser expands and displays additional search options.
3 Type in the medication name, select any additional options and click Search.
4 The Formulary Browser displays the results of your search.
5 Double-click on the desired medication to prescribe it.
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Using Mail Order Pharmacies
The following Mail Order Pharmacies participate in RxHub (this list is subject to change) o Caremark Mail Service Pharmacy o ESI Mail Order Pharmacy o Medco Mail Order o Prime Mail o Wellpoint NextRX Mail Pharmacy o Prescription Solutions Mail Order To successfully send a Mail Order prescription, the following must take place o Provider MUST be enrolled in RxHub o Patient MUST be Mail Order eligible o Medication MUST be selected from the formulary browser Once all conditions are met during the PHARMACY search there will be a box “MAIL ORDER PHARMACIES ONLY” to check during search. (It will appear just under phone/fax in the pharmacy search window)
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Using the Visit Templates
and Clinic Workflow
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Peds MA/Nurse Workflow
When EHR launches the first screen that will appear is Workflow. You will see all appointments and
tasks in this window. From the appointments window select the patient that you are going to room.
The “Status” should display as “Checked In”. Right click on patient’s name and select “Go to Patient’s
Chart”.
You are now in the patient’s chart.
You will need to STOP and do a 4 point check. Do you have the correct patient, location, provider
and date?
1
.
3
.
2
. 4
.
When you have verified these 4 points you will select the
Templates icon. From the Preferred list you will select “Intake-
OV” and select OK.
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Intake PEDS Template
Input type of patient (New or Established). The system should default to Established if the patient
has previous encounters.
Select the Template Set by clicking in the blank field. From the list select Family Practice.
Select the Visit Type. Office Visit = Sick, Preventative = Physical, Annual, Well Visit.
Select the Reason for visit or chief complaint from the list that appears when clicking in the blank
field. If Preventative visit select physical exam or well visit. If there is a blank space you can enter
free text. A Well Child Visit will automatically populate Well Visit as the Reason for Visit.
Select the HPI Detail button to enter information on the chief complaint.
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Reason for Visit – HPI Detail
Each reason for visit is linked to an HPI template. There are 3 kinds of templates we will focus on –
problem specific, Quick Visits and Generic. If you free type a Reason for Visit it will always pull up the
Generic HPI. Nurses and MA’s are required to get the basic information located in the top half of the
template.
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Entering Vitals
Select the Add button
Enter the vitals that you currently collect in the pop up template that appears. You may use the large
key pad to the left or your keyboard to enter the values. You can also tab through the fields. This will
automatically calculate the patient’s BMI. When you are finished select Save and Close.
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Reviewing Medications
You will review the patients’ medications the same way you currently do by interviewing them. On the
Intake template either indicate “No medications” by checking the box or selecting the “Reconcile”
button if they have current meds. Make sure to ask them if they are taking any Over the Counter meds
and if not, check the No OTC box, and if so add to the Med Module.
Medication Reconciliation
Select the verify mode checkbox. Single click on each medication listed under Medication Module as
you ask them about that medicine. The medication will drop to the “Medication Reconcile” box at the
bottom of the template. Enter ONLY if the patient needs a refill or is not compliant as ordered. After
each medicine is entered select Save. When you have completed all select Save & Close. Required for
MU measure - You must BOTH check the box “Completed for Transition of Care” on the Medication
Reconcile template AND enter a listed Interim History to complete this measure.
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Reviewing Allergies
You will review the patients’ allergies as you do currently. You will document on the Intake template by
selecting No know allergies, Reviewed, no change or Allergies added today if there was new information
added.
Begin by double clicking in the Allergies grid
Click on the magnifying glass
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Type 3 characters to begin:
Double click on the allergy to select:
Search
Results
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User can enter a Severity, Reaction, and Allergy Comments if appropriate. Click the “Add” button to complete the process:
Add additional allergies as warranted, by clicking again:
Peds Review of Systems Well Visits require that you gather Age-Specific Interval/Social History and completed a Developmental History. Access the templates by clicking on the links.
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Age-specific Interval/Social History Fill out only the information that your practice currently gathers via the patient history forms and be sure to select a radio button under Last detailed doc date. This information will carry forward to the corresponding fields on the History Tab
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Developmental History Enter the data in the appropriate section by clicking on the Detals link. Add information Developmental Screenings – the MCHAT and PSC are embedded in NextGen. Any other screenings, such as Ages and Stagers can be entered by clicking Add New
And selecting or entering the name of the screeing tool and any other pertinent data.
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Standing Orders
To result standing orders (urine dipstick, glucose fingerstick, pregnancy test) you will select the Office
Diagnostics link at the bottom of the template.
Select the test from the list with a single click. The information appears below the list. Select the Detail
button and complete the pop up template. Select OK. Select Place Order and then Close. The provider
will now see these results prior to going into the Exam room.
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Entering Histories on the History Tab
Select the Histories tab across the top.
Interim History
Required for MU measure. When adding Interim History, you must check the box “Completed for
Transition of Care on the Medication Reconcile template.
Begin with Interim History – any hospital stay, urgent care, outpatient surgery or ER visit since the
patients’ last encounter.
Select Interim History
Complete the pop up template that appears. Only input the pertinent information (type, problem, date,
hospital) if the patient knows and will disclose. When complete select Save and Close. If there is more
than one incident to document select Clear for Add before entering the next.
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Medical and Surgical History
Select the Update button
Select the past medical history from the group of checkboxes at the top of the template and the surgical
history from the middle. If you cannot find your disease or procedure use the “Additional History”
section at the bottom of the template to search for the item. If there is more than one to document in
the “Additional History” section select Save & Add New, if not, select Save & Close.
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Family History
Select the Update button
Choose the family member that you wish to document. You only need to indicate Yes for a disease if
that family member has it. If you know age of onset or death you can complete that. If the disease was
a cause of death you check the box under #3. If you are documenting more than one family member
select Save and the screen clears for the next set of information. When complete select Save & Close.
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Social History
**Tobacco Usage must be captured for Meaningful Use**
Select “Tobacco Usage” and complete the pop up template. Complete Alcohol Use, Marital Status and
exercise type and frequency.
Complete tobacco use for anything other than cigarettes and smoking status for cigarette smoking
status. It may be “never” for both, but complete both! Select Add and Save & Close.
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Check Out Tab - Discharging the patient
When the provider is finished with their portion of the visit you will see the status change in the inbox to
“ready for checkout” OR be told by the provider. Right click on the patient as you did at the beginning
of the visit and select “Go to Patient’s chart” or double click to open.
Select the Intake PEDS template from the History window.
Select the Checkout tab
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All orders, medications, referrals, patient education and follow ups will appear in the grids on this
template.
Labs, Referrals and Diagnostics will be printed. Select the line in the grid and select the Requisition
button.
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Injections
The Office Services grid will contain injections that need to be administered. You are going to document
that the shots are given here. The provider will order them and task them to you.
For all orders that ARE NOT immunizations you will select the item in the grid and double click. You are
going to select the “Performed” checkbox and input the information. When it is a lab like a Urine dip,
you will need to select When complete select Save and Close.
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Immunizations
When you see any order in the list that is an immunization you will need to go to the Immunizations link
on the left hand navigation.
Scroll down the template to the grid titled “Immunizations and Titers Ordered at This Encounter”.
Double click on the immunization that you are going to document.
Complete the Site and click in the Lot Number field. A list containing the Lot Number, Manufacturer and
Brand Name will pop up. Choose the appropriate vaccine given..
Select the Immunization given check box and then select Save and Close.
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Navigate back to the Check Out using the history window.
Patient Plan
Required for MU measure. The Patient Plan will be printed and given to the patient at each visit. Select
the “Patient Plan” button and the document that is generated should be printed and given to the
patient.
The check boxes at the bottom of the Check Out template should be used to document what was given
or refused by the patient. If any of the items listed were given or ordered for the patient select “Yes”.
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Peds Provider Workflow
From the Workflow Module, double click on the patient to be roomed (Status should be “waiting for
provider” if they have checked in at the front desk. Immediately conduct a Four Point Check:
Patient, Location, Provider, and Encounter Date.
Click on the Templates icon on the Tic Tac Toe grid.
Select the *Summary template and click OK.
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Summary tab
The Summary tab is a place to overview Chronic problems, orders, vital signs, medications, allergies,
and previous assessments. Use the Order View to “flip” to the various sections in the chart.
The Order view can be filtered by the selections below. This will display all previous orders that
have been input during the patient’s previous visits.
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Chronic problems can be updated and addressed by selecting the Add Problems button.
The medications and allergies can be reviewed on this tab.
The patient’s medications can be verified by selecting the Reconcile button.
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Medication Reconciliation
The medications will have dropped to the “Medication Reconcile” box at the bottom of the template.
You can verify the compliance if the MA or Nurse has entered it.
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Reviewing Allergies
You will review the patients’ allergies that have been input by the nurse. You will document on the
template by selecting No known allergies, Reviewed, no change or Allergies added today if there was
new information added.
Begin by double clicking in the Allergies grid
Click on button:
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Type 3 characters to begin:
Double click on the allergy to select:
Search
Results
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User can enter a Severity, Reaction, and Allergy Comments if appropriate. Click the “Add” button to complete the process:
Add additional allergies as warranted, by clicking again:
The Assessments/Office Visits grid will display according to the radio button selected. It will give you the
assessments (diagnosis) or visit types for past encounters.
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Histories tab
When you are finished with the Summary tab and ready to review/update the patient’s histories you can
move to the Histories tab.
Medical/Surgical/Interim History
This grid is where interim histories (such as ER visits) are documented. It contains all past medical
conditions and past surgeries. Nursing inputs this information. You must select either Reviewed, no
changes, Reviewed, updated, No relevant medical/surgical history, or History unobtainable.
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Family History
This grid is where the health of immediate family is documented. Nursing inputs this information. You
must select Reviewed, no changes, Reviewed, updated, No relevant medical/surgical history, or History
unobtainable.
Social History
The patient’s tobacco, alcohol and exercise information appear on the main template. More extensive
social history can be reviewed by selecting Update. You must select Reviewed, no changes, Reviewed,
updated, No relevant medical/surgical history, or History unobtainable.
Smoking Cessation
Click on the “Tobacco Cessation” button to open the Tobacco Cessation template and fill in applicable
fields. Then click the “Save” button and the “Close” button to return to the OV Template.
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SOAP Tab
When you have reviewed the Summary and Histories tabs, you are ready to begin the patient’s visit on
the SOAP tab
HPI
Read the HPI Detail and enter any additional information on paper
Enter the remainder of your HPI, ROS, Physical Exam and any Procedures on paper for later scanning
Assigning diagnosis Click inside the first blank Assessment field.
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Add to today’s assessments utilizing the patient’s “Diagnosis History”, “Chronic Problems”, and “My List”fields. Provider can also click Add Common Assessment to choose from a pop up template filled with specialty specific diagnosis codes. To search all diagnosis codes, click the first blank assessment field. Click “Save & Close”.
Click on the “My Plan/Orders” button
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The tabs along the top of the template give the provider options for constructing a plan for the patient.
The My Plan template allows the provider to customize diagnostics, labs, procedures, and instructions
based on assessment. These “order sets” are provider specific and once saved can beused for any
patient with the same diagnosis. You must enter Instructions and Follow-Up Visit in order for it to
appear on the Patient Plan.
The Plan Details tab allows the provider to “free text” on each assessment. The “Common Phrases” and
“My Phrases” features are available on this template.
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The next three tabs are where you will place orders. You may or may not order all three for any given
patient. Each tab has a Save & Close” button in the lower right corner. When you have ordered all that
you need to, click on “Save & Close” to return to the SOAP Template.
Each of these tabs allows you to select the appropriate time frame for you order. It defaults to today, so
if you want to place future orders, you will need to adjust the time frame section.
The Labs tab allows the provider to order send out labs. Click on the appropriate diagnosis, click desired
labs, and click “Place Order”.
Lab subtemplates will also have a Place Order button, but do not drop to the Order grid until the Place
Order button on the main Lab Master template has been pushed.
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Diagnostics tab is functionally similar to Labs. Click on the appropriate assessment, choose the
diagnostic study with any other necessary info (side, site, modality), and click “Place Order”.
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Referrals tab is used to create specialist, DME, and therapist referrals. Choose a radio button in the To
section for the appropriate referral you want to make. Choose the appropriate diagnosis. Fill in
applicable treatment and clinical information. You must fill in the To, Diagnosis and Services Requested
section in order to process. Click “Place Order”.
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The Office Procedures tab is used to order in office DME, Injections (not immunizations), Spirometry,
etc. Click the appropriate assessment, choose the procedure with pertinent info (Dose, Strength), and
click “Place Order”. You can also document if you personally performed the service as well by checking
the box in the lower left corner of the template as well as indicate that it is a future order
Once you return to the SOAP page, click the Meds button to add or adjust medications in the
Medication Module and use the Well Visit link (which will only appear if a well child age was chosen on
the Intake PEDS tab.) to enter Anticipatory Guidance. You may add additional Plan Comments as
necessary. These comments will appear in the Patient Plan.
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Do not enter data in the Office Services or Immunizations sections – only use the Anticipatory Guidance
sections and check the box if you gave handouts.
Click on the “Patient Plan” button to generate a document for the patient that includes today’s
assessment(s)/plan, medications, and orders. Click on “Chart Note” to generate the final document for
the encounter. Click “Next” to take you to the Finalize Template to submit your visit for review if you
are a supervised provider.
Finalize OV tab
If you require sign off, you will go to the Finalize OV tab and in the Provider Sign Off section in the lower
left of the template and check the box for Physician Sign Off Request. Supervising providers will also
have to come to this page to use the Supervising Physician Sign Off section once they receive the task
that it is ready.
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Meeting Meaningful Use in Next Gen
Several key indicators of care are directly obtained from the Next Gen EHR program. The 8.0
KBM offers "Meaningful Use" reporting of elements. This tool has been developed to assist end
users with documentation in Next Gen.
Vaccine Documentation
All vaccines need to be recorded in the Immunization template within Next Gen. Vaccines
administered by CHESI may be pulled for reporting by searching for the CPT code associated
with the vaccine administered. Any vaccine not administered by CHESI, should be entered in
the "Previous Immunization" template with the appropriate sequence number if it is known.
Adult
Immunization
Template
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Pediatric
Immunization
Template
Previous
Immunization
Template
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Vital Signs
All vital signs should be recorded within the "Vital Signs" template within EHR for patients over
the age of 2.
BMI- A height and weight need to be recorded in the same unit of measure for a BMI to
calculate. There is an ability to select "carried forward" for a height recording from a previous
visit. This template contains a link to the BMI Plan template for any abnormal findings.
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All Orders Placed in the EHR
All Orders for a patient visit must be placed in the EHR – this includes outside labs, referrals &
diagnostics.
Plan recorded in the EHR
Plan must be recorded in the EHR to generate on the Patient Plan. Plan must be printed and
given to patient before they leave the clinic. Plan can be generated at the bottom of the Check
Out tab or SOAP note.
Asthma
Audits are based upon patients with the diagnosis of asthma in the assessment template and a
status of persistent who have been prescribed an inhaled corticosteroid in the Medication
Module. The administration of an annual influenza vaccine is also reviewed. The influenza
vaccine would follow the same guideline for vaccine documentation listed earlier in this
document.
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The status must be indicated on the Asthma Flowsheet, accessed off the Chronic Conditions HPI
Template by clicking on Flowsheet, selecting Asthma and choosing Update.
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The Pediatric Asthma Flowsheet is used to track patient progress
Tobacco Usage
The 8.0 KBM contains a specific area for documentation of tobacco status. This may accessed
by selecting the "Tobacco Use" link in multiple templates which takes you to the Tobacco Use
template. The Tobacco Use section, along with Smoker Status on the Tobacco Use template will
need to be completed at the top of the grid and the Add button selected to meet requirements.
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History Tab Link
Tobacco Cessation Template Link
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Screening Summary Link- This is found on the Intake and Summary tabs.
Patient Education
The system records orders that are under "EDU" or "INSTRUCT" as meeting this requirement.
The "My Plan" has an area to place instructions. Anything in this area of the template that is
marked for a patient with a check mark and the order is placed would qualify.
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Counseling documentation for tobacco cessation or using the BMI plan link from the Vital Sign
template would also qualify for measure.
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The Pediatric WCC anticipatory guidance template records sections as patient education and
would also meet this requirement.
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The Screening Summary template also contains a link to the "Counseling/Educational Details"
template.
