Transcript NEXTGEN PRENATAL INTAKE VISIT DEMONSTRATION

NEXTGEN
CHRONIC CONDITIONS VISIT
DEMONSTRATION
This example demonstrates some workflow options for a visit that
primarily deals with the management of chronic diseases, using the
“Advanced Template Set” employed by Family Medicine, Internal
Medicine, and Pediatrics. Details of the workflow will vary somewhat
depending on specialty and practice policy, but this should give you a
good idea of NextGen functionality.
This has been prepared with EHR 5.6.5.63 and KBM 7.9.2, though some
screen shots may display the appearance of earlier versions if they are
not directly pertinent to the issue being discussed. Wherever germane,
however, screen shots have been updated to the most recent
appearance.
Use the keyboard or mouse to pause, review, and resume as necessary.
There is no audio with this exercise.
Warning
• At present Protocols, which are an integral
part of chronic disease management,
manifest in an undesirable and misleading
manner in visit notes. While they can be
used, the user will have to manually review
and edit the Assessment/Plan section of
the visit note to correct inaccuracies.
• As a result of this and other current
technical problems, most users may be
better off avoiding the use of protocols
for now.
Introduction
• There is a “Chronic Conditions HPI” template,
which allows the management of chronic
diseases in a comprehensive manner, and in
parallel with any acute presenting problems.
• This tool has great potential, and is being
incrementally improved over time. However,
there are still a few quirks we have to work
around.
• This exercise will provide some pointers on
how we can best use this template in its
current condition.
• The Chronic Conditions HPI popup will be
launched if any of the following chief
complaints are activated:
– Chronic conditions
– Diabetes (follow-up)
– Heart disease (follow-up)
– Congestive heart failure (follow-up)
– Hypertension (follow-up)
– Hyperlipidemia (follow-up)
– Kidney disease (follow-up)
• But other chronic diseases may be
addressed through the Chronic Conditions
HPI popup as well.
Introduction
• “Protocols” are set up and activated for
the patient, to assist with chronic disease
management (and health maintenance).
• These protocols can be modified as
desired by the provider to personalize
them for the patient. (The setup of
protocols will be reviewed in another
lesson.)
• After that, the recommended measures
are incorporated into the regular visit
workflow.
The nurse opens the chart to the Intake template.
Select New/Established, Template set, and Visit type
as necessary.
In this example, the patient is a 40 year old male in for
follow-up on diabetes and hypertension.
Patient
Location
Provider
Date
Perform the 4-Point check.
Click Add to enter Vital Signs.
Enter Vital Signs. (Details are
reviewed in a separate exercise.)
Data used in this example:
Ht 6 ft, 1 inch. Wt 199 lbs, dressed without shoes.
T 98.8, orally.
BP 148/86 sitting, left arm.
HR 80. Resp 16. BMI of 26.12 will be calculated.
When done, click Save, then Close.
Review the patient’s chronic medical problems. We note
the diagnoses of diabetes, hypertension, and tobacco
abuse; there is nothing new to add.
Review the medication list. If desired or necessary, doubleclick on the Medications grid to open the full Medication
Module.
In this example, we note he’s on Cozaar
50 mg daily and metformin 500 mg BID,
but have nothing else to add, so close the
Med Module. (Use of the Med Module is
reviewed in another exercise.)
Review the allergy list. We
have nothing to add, so
click Reviewed, no change.
Next, click in the 1st
Reason for Visit box.
There are a few appropriate choices,
including chronic conditions, the
DM/HTN combination, and diabetes and
hypertension separately.
Here we’ll select DM/HTN. (He has no
acute complaints today.)
In this example, the office has a standing order for the
nurse to perform a sugar and a HbA1c on diabetics.
The nurse performs these tests. To enter them, click
Office Services (sometimes labeled Office Diagnostics).
Click in the Display order set
box and select Office Tests.
Scroll down until you see Glucose blood test
associated with Diabetes 250.00; click on this line.
Click in the Detail box and enter the result of 188.
Click Submit to Superbill,
then Place Order.
In a similar fashion, select Hemoglobin A1c associated
with Diabetes 250.00, enter a result of 8.2, Submit to
Superbill, then Place Order.
When done, click Close.
Move to the Histories tab and review details. In this
example, we have no changes to make. (It may have been
more convenient to do this earlier while discussing the
items on the Intake tab with the patient.)
The patient is ready for the provider.
Click the Tracking icon.
In the Room box, enter Exam 1.
In the Status box, enter waiting for provider.
Click Save and Close.
Patient
Location
Provider
Date
The provider then opens the chart, performs the
4-point check, and reviews the data on the
Intake tab. (Alternatively, the provider may
start on the Summary or SOAP tabs.)
Note the solid diamond at Office Services.
This indicates that the nurse has entered
something, so click that.
Note the HbA1c and glucose results.
When done, click Close.
Review the Histories tab. (Update information as
necessary, and note items you may wish to discuss
further with the patient.) Select a Review Bullet
in each section to indicate the amount of detail
you would like in today’s note.
When done, move to the SOAP tab.
Click HPI Detail.
The Chronic Conditions-HPI popup appears.
There’s a lot to review here, so let’s orient ourselves.
Click the Flowsheets button.
In these two screenshots, we’ve
displayed brief examples of the
Diabetes and Hypertension
flowsheets.
When done, click Save and Close or Cancel.
You can enter his home BPs,
or a range of home BPs.
Home glucose readings can be
entered by clicking Home Glucose
Readings.
When done click Save and Close.
Lab results can be reviewed.
Click Lab Review.
In-house labs can be reviewed, if not noted earlier.
You can also review outside labs that have been done at
LabCorp.
When done click Save and Close.
Associated symptoms/pertinent negatives is the
Review of Systems section. You can document a few
symptoms directly, or click the Add button for a
more complete ROS.
This is the regular Review of Systems popup.
Note you have access
to your ROS presets.
When done click Save and Close.
The med list appears here.
Click Medication Review.
Review meds, noting that he sometimes misses Cozaar—
especially pertinent since his BP is up a little.
(Reconciliation takes on a different meaning when you are
transferring care from one location to another, and you
have another electronic med list to compare to, but we’re
not in a position to demonstrate that yet.)
When done click Save and Close.
One way to record the “HPI” aspect of a
chronic disease is to click the Address button.
Select one of the chronic
conditions to address.
Select a Status if desired.
(You’re not required to do so.)
Add your notes. (You can use
My Phrases for this as well.)
When done, click Add.
Repeat the process as desired for the other diagnoses.
When done, click Save and Close.
In addition to (or instead of) the comments
you just added, you can add further notes by
typing in the Free text (comments) box.
For example, here you might type:
Sometimes missing Cozaar; not following low-salt diet.
Using metformin as directed; sugars running 110-150 on
home checks. Still smoking; not interested in quitting at
present.
Note the Protocols section; several protocols have
been activated for this patient. Here we’ve
selected to view items Due within 1 Month.
You can double-click on an item to manage details about it
without having to go to the Protocols tab.
This is useful to document items done during the visit, or
things previously done, though items like referrals and
outside tests will be ordered later.
When done, click Save and Close.
Finally, look at the Recommended
Care section. You can select the
Addressed today bullet to show
recommendations for diagnoses
you’ve addressed today, or All to
display recommendations for all
the patient’s chronic conditions.
This Recommended
Care section can be
used as a “reminder
list” for things you’ll
document/order later,
or you can complete
some of them here.
To demonstrate, double-click
on Smoking Cessation.
Complete the information in the
popup, then click Save and Close.
Scrolling down further, we’re reminded that
he’s not taking an antiplatelet drug.
(We’ll discuss this with him and add it in the
Medication Module later.)
Note that Recommended Care is somewhat liberal, and may
include items that the provider does not deem appropriate
for every patient. Sometimes multiple alternatives are
presented, e.g. ACE-Is and ARBs for diabetics. You’d
probably only pick one of these, but it will still show all the
recommendations. These measures should be addressed on
a case-by-case basis.
Also recognize that it may not be feasible to address all of
the Protocol and Recommended Care items within the time
constraints of a single visit, but they serve as useful
reminders to help you avoid repeatedly overlooking these
measures.
When done, click Save and Close.
Now click Physical Exam.
If you used the “Address”
popup to enter comments on
Chronic Conditions HPI, the
problems you’ve just
addressed are added to the
assessment list. (If they’re
not added, you’ll see how to
manually add them shortly.)
Enter your physical exam.
Note you can save and use
preset physical exams.
Note that you can add exam notes, and click the Carry
forward comments checkbox. This way these notes will
appear on future exams without having to re-enter
them—and will help you avoid inadvertently documenting
conflicting normal findings.
Click Save and Close when done.
Note that your exam
comments also display here.
If you’ve addressed chronic
problems through the
Chronic Conditions HPI
popup, they may already be
listed among today’s
assessments. If not, click
in the first available
Assessment field.
Note that hypertension, diabetes, and tobacco abuse
appear on the Diagnosis History and Active Chronic
Problems lists. You can click on these, and they will be
added to Today’s Assessments.
When done, click Save and Close.
To enter plans, click My Plan/Orders.
The Plan Details tab gives you the
chance to type instructions/plans
for each problem. You can also
use My Phrases to insert text
that you use repeatedly. (Use of
My Phrases is reviewed in
another exercise.)
Now move to the
My Plan tab.
The My Plan tab gives you the opportunity to
add labs you frequently use and associate
them with all the diagnoses on the Chronic
Problem List and Today’s Assessments.
Highlight the hypertension diagnosis, and any
preset tests and therapeutic measures
display. We’ll order a BMP, Hepatic Function
Panel, and Lipid Panel.
We want to see him back
in 4 weeks, so enter that
here as well.
When done, click Place Order, thus
ordering the BMP, hepatic panel, lipid
panel, and 4-week follow-up appointment.
Since he is a diabetic, we also want
to order a urine microalbumin.
Highlight diabetes, and click
Microalbumin/Creat Ratio.
Then click Place Order.
If you need to place a lab you can’t
easily find or add to My Plan, you
can use the Labs tab…
…or the Order Module.
(These are demonstrated
in other lessons.)
For the purposes of this exercise, we have ordered all the
lab work we need today.
Click Lab/Diagnostics/Radiology Order Module Processing.
(Note: If you clicked Save and Close, this module would
display spontaneously.)
Also note: Depending upon clinic-
specific policies and workflow, these
next steps may be performed by the
nursing or front office staff.
The lab work ordered today displays. If LabCorp
has previously been used, it will probably display in
the Vendor box.
If necessary, click in the
Vendor box, and select
LabCorp.
Click on BMP, then click the
Include selected order button.
The BMP moves to
the bottom grid.
Repeat this for the 3 remaining
orders. But note that if you click
the Automatically perform…
checkbox, the tests will move to
the bottom grid just by clicking on
them, saving you a few clicks.
Notes:
1) To avoid sending fictitious lab requests to LabCorp,
please do not click Process/Submit on practice patients.
2) For the near future, USA Pathology and Radiology
studies will not be handled through this module.
When done, click Process/Submit, then Save and Close.
Though they are not needed for this patient, briefly
note the Diagnostics, Referrals, and Office
Procedures tabs that are available. (More details on
the use of these templates are reviewed in other
exercises.)
The Diagnostics tab is where radiographic studies are
ordered, both for in-house X-rays, and studies performed
at the hospital.
The Referrals tab is where referrals to
specialists and therapists are ordered.
The Office Procedures tab allows ordering of various
office services, though there are often other places
where it would be more convenient to order most of
these items.
When done with everything
here, click Save and Close.
Return to the SOAP tab.
Suppose we’ve planned a flu and pneumovax;
we still need to order them. In some clinics,
this may just be verbally communicated to the
nurse. To actually order them, however,
display the Nav Bar and click Immunizations.
If necessary, answer the
allergy questions.
Select pneumococcal (PPV23).
It’s his first pneumococcal
vaccine, so click 1.
Similarly, order the flu shot.
He’s had a flu shot before,
so click booster.
Click Place Order.
(A tasking popup will appear; if
you’re going to verbally
communicate this to your nurse,
you can just cancel out of it.)
If you scroll down a bit, you’ll see
the ordered vaccines on the grid.
When done, use the
Nav Bar to return to
the SOAP template.
We need to prescribe some medications. Click Meds.
We’ll leave Cozaar unchanged, increase metformin to
1000 mg BID, and add daily aspirin. After making
those entries and dispensing the prescriptions, close
the Medication Module.
(A thorough review of the Med Module is included in
another exercise.)
When done, close the Med Module.
You can add any closing
comments you’d like to
appear at the bottom of
the visit note.
You can generate the
Patient Plan here, or from
the Finalize or Checkout
tabs.
The Patient Plan is the visit
summary required as one of the
Meaningful Use measurements.
Edit as desired, then print this
for the patient.
When done, close the document.
Move to the Finalize tab.
Select a level of Medical decision
making and click Calculate Code.
If you are satisfied with the
recommended code, click Submit Code.
Residents will submit the note to the
supervising attending.
In addition, a resident needs to
view encounter properties to set
the Supervising Physician for
billing purposes.
Right-click on the encounter
folder and select Properties.
The resident doctor clicks
the Supervisor dropdown
arrow, and selects the
attending.
In this example, we’ll use
Dr. Duffy.
Click OK to close the popup.
You’ll probably want to generate the note
offline. To do this, hover the mouse over
Navigation.
When the Navigation Bar
displays, click Offline.
Once the visit note has been
generated and billing is complete,
you are done with this encounter.
This concludes the
NextGen Chronic Conditions
demonstration.
If all the world is a stage, where is the audience sitting?
This concludes the
NextGen Chronic Conditions
demonstration.
If all the world is a stage, where is the audience sitting?