1. NEXTGEN WORKFLOW DEMONSTRATION Adult Patient With Bronchitis, Hypertension, & Diabetes This demonstration works through a sample adult encounter. This has been prepared with EHR 5.6.5.x and KBM 7.9.1-7.9.2. Subsequent updates may display cosmetic and functional changes. Slides are updated if the changes are pertinent to the points being illustrated. Use the keyboard or mouse to pause, review, and resume as necessary. There is no audio with this exercise.

2. The nurse begins by right-clicking on the patient from her provider’s appointment list, and selecting Go to Patient’s chart.

3. Some users may see an alert like this. If so, just click OK.

4. The chart opens to the nurse’s default template; in Family/Internal Medicine and Pediatrics, this will be the Intake-OV template. (The chart will often open directly to this template.)

5. Perform the 4-Point check. Patient Location Provider Date

6. If necessary, select New vs Established Patient. In this example, our patient is Established.

7. Enter Template set, Visit type, and Historian. In this example, we’ll use Family Practice, Office Visit, and Self, respectively.

8. Note that the Navigation Bar is collapsed on the left.

9. It will slide out if you hover over it. But you should be able to do most of your visit moving from left to right on the tabs across the top of this window.

10. Also note the History Bar does not display by default on the right.

11. You can display and hide it by clicking the History button. This helps make better use of the full width of the screen—especially useful when working on a smaller computer.

12. Note the Alert button; click this to review.

13. This gives you the opportunity to indicate several noteworthy alerts about the patient. Our patient requests that we release No information to family, so click that box. Additional comments can be entered below. Click Save and Close when you’re done.

14. If an alert has been entered, the button will change from a white and blue oval to a red rectangle. This is visible on other tabs as well. Also note the Sticky Note link; click this to review.

15. Enter other notes that may be helpful, but don’t rise to the level of an “alert.” Click Save and Close when done.

16. If a Sticky Note has been entered, the link changes to a lighter blue, and there is a solid diamond next to it. These alerts and sticky notes will now be removed.

17. Now click Add to add Vital Signs. The Alert and Sticky Note links return to their unused appearance.

18. Enter Vital Signs. (Details are reviewed in a separate exercise.) Data used in this example: Ht 6 ft, 1 inch, measured today. Wt 199 lbs, dressed without shoes. T 97.7, orally. BP 167/123 sitting, left arm, manual adult cuff. HR 84, regular. Resp 24. BMI of 26.25 will be automatically calculated.

19. Click the Standard to Metric button to display the metric conversions for your entries.

20. When done, click Save, then Close.

21. Review the patient’s chronic medical problems. To add problems, click Add Problem.

22. There are multiple ways to search for problems. Our patient is a type 2 diabetic. For this example, click All to search for this diagnosis.

23. The familiar search popup appears. Using the method of your choice, search for diabetes. In this example, we’ve scrolled down to Diabetes mellitus without mention of complication…250.00. Double-click on that line.

24. The diagnosis is displayed. Enter Date of onset and Additional information to the extent known/pertinent. Click Save and Add New.

25. The cursor will still be in the Date of onset box. Just type 11111111, then save your entry as described above. A Note About Date of Onset NextGen sometimes makes this a required field. However, there are many times when you will be entering data such as this, but won’t know the Date of Onset, and may not have the patient available to ask. Our recommended workaround is to enter the date 11/11/1111. Click in the Date of onset box. This brings up the Calendar popup. Click the X to close it.

26. The patient also has essential hypertension. Let’s say we know the code we want to use for this is 401.1. Click in the Code box.

27. A Diagnosis Code Mstr popup appears. Type 401.1.

28. 401.1 Benign essential hypertension displays. Double-click on this.

29. He tells us the hypertension was also diagnosed about 2 years ago, so we’ve entered 1/1/08. That’s all the chronic problems we have to enter. NextGen is inconsistent in windows like this as to whether you have to click Save and Add New before clicking Save and Close, so it is best to get in the habit of clicking Save and Add New, then Save and Close.

30. These chronic problems now display, though you may have to use the scroll bar to see them all.

31. If you display the History Bar, you can also bring up the Med Module in a tab by clicking on the Med Module here. Since this is the first encounter documented in NextGen, we need to add the patient’s medications. You can open the Med Module by double-clicking on the Medication Grid.

32. A detailed discussion of the Medication Module is included in another lesson. In this example, our patient is taking: Cozaar 50 mg daily. Metformin 500 mg twice daily. Add these medications, then close the Med Module.

33. These meds now display in the Medication grid.

34. Next, review allergies. He states he is allergic to tetracycline, so double-click on the Allergies grid.

35. Add the patient’s allergy to tetracycline; he gets a moderate rash from it. (A detailed discussion of the Allergy Module is covered in a separate exercise.) When done, click the X to close the Allergy Module.

36. Tetracycline now displays in the Allergies grid. Since this was just added, click the Allergies added today bullet. Now we’ll add some chief complaints. Click in the first Reasons for Visit box.

37. The patient is complaining of cough, so select cough.

38. Cough now displays in the 1st box. The patient is also here for his diabetes and hypertension, so click in the 2 nd Reasons for Visit box.

39. Since diabetes and hypertension are so often seen together, there is a listing for this combination. Click DM/HTN.

40. DM/HTN now displays in the 2 nd box.

41. Some offices may have the nurse or medical assistant document part of the HPI for acute problems. Select the bullet next to cough, then click HPI Detail.

42. One of NextGen’s suggestions is to have the nurse document the details in the blue shaded area at the top, and any other symptoms on this popup that the patient volunteers. Our patient’s cough began 3 days ago, is moderately severe, gradually worsening and persistent. He adds that no OTC meds have helped.

43. Click in the Onset box. This popup will appear. (If you click the dropdown arrow, you can choose between “gradual” and “sudden.” Use the popup to enter 3 Days, then click Save and Close.

44. Click the Severity dropdown arrow and choose moderate-severe. (If you click in the box, you can choose a severity on a 1-10 scale.)

45. Use the bullets and checkboxes to document the other details given.

46. When done, click Save and Close.

47. The nurse can add other comments by clicking Intake Comments.

48. Type comments as desired, then click Save and Close.

49. Now move to the Histories tab. The words Intake Comments become lighter blue, and the diamond in front of them becomes solid, indicating that something has been entered.

50. The nurse reviews/enters Past Medical/Surgical history. Episodic historical items should be entered here; chronic problems should be entered in the Chronic Problem List as demonstrated above. Double-click on the Past Medical/Surgical grid.

51. Our patient had a left inguinal hernia repair in 2002. Select the Gastrointestinal bullet, then click in the Disease box.

52. In the ensuing popup, select Hernia, inguinal.

53. Enter Side LT and Year 2002. Next click in the Management box. In the ensuing popup, select inguinal hernia repair.

54. Click Save. We have more history to enter, so click Clear for Add.

55. He had an L4-5, L5-S1 discectomy & fusion in 2004 for disc problems. Select the Musculoskeletal bullet. In the ensuing popup, click Degenerative disc disease.

56. Enter Year 2004. Click in the Management box. There isn’t a perfect choice on this popup, so click on the blank space at the top of the list.

57. Type his surgical details. You can add further notes and clarifications here. We have nothing else to add, so click Save, then Close.

58. These additions display in the grid. Since this is the first visit documented in NextGen for the patient, click the Detailed document bullet.

59. The patient had a negative cardiac stress test in 2009. To enter that history, click the Past Diagnostics link.

60. In the Diagnostic History popup, click in the Diagnostic study type box. In the ensuing popup, select Cardiology Studies.

61. Select Cardiovascular stress test, complete.

62. He doesn’t know the exact date. A reasonable option is to enter January 1, 2009, then click the Approximated performed date box.

63. Enter the result and any other comments as appropriate. His test was Normal. Click Save and Add New. (It is necessary to click this before clicking Save and Close, to add this item to the Diagnostics History grid.)

64. Now click Save and Close. The test now appears on the Diagnostics History grid.

65. To enter the Family History, click the Update button. (Double-clicking the grid would give you an alternate method of entry.)

66. His brother has hypertension. Click the Brother bullet, then the Hypertension Yes bullet. Click Save.

67. His mother died from alcoholism at age 52. Click the Mother bullet, then the Alcoholism Yes bullet. Click Save, then Save and Close. (You must click Save before Save and Close.) Type 52 in the Age box, then click the Cause of death button.

68. These additions display in the grid. As above, click the Detailed document bullet.

69. Move to the Social history. He drinks about 1 drink a day on the average. Enter that directly here. To enter tobacco history, click the Tobacco Usage link.

70. He has smoked a pack a day for 20 years. Enter that here, then click Add. When done, click Save and Close.

71. You can also enter Confidential Info and Tobacco Cessation information. As above, click the Detailed document bullet.

72. Scrolling down, more Social History details may be added. The patient is right-handed, and works as an accountant.

73. The patient is ready for the provider. Click the Tracking icon.

74. In the Room box, enter Exam 1. In the Status box, enter waiting for provider. Click Save and Close.

75. Patient Location Provider Date The provider then opens the chart from the appointment list and performs the 4-point check, as previously demonstrated.

76. The Summary tab is NextGen’s recommended starting point for the provider. Begin by taking note of any Alerts or Sticky Notes that have been entered. In this case there are none.

77. If the nurse has entered any Intake Comments, the link displays in a lighter blue, and there is a solid diamond next to it. If Vital Signs are not normal, you are alerted.

78. Chronic problems, vital signs, meds, and allergies can be reviewed here.

79. Click in the Order view box. Note that while it initially displays vital signs, several other items can be displayed here. You will also want to review the Histories tab.

80. Review/update Past Medical/Surgical, Family, and Social Histories, selecting the appropriate review bullets. When done, move to the SOAP tab.

81. Review the Reasons for Visit. Note that the nurse has entered some details about “cough.” Click HPI Detail to further document this HPI.

82. We add that the patient is a smoker, and is having a green productive cough. He denies fever and sore throat, but is having nasal congestion, drainage, and sinus pressure. When done, click Save and Close.

83. Now click the DM/HTN bullet, then click HPI Detail. These details display.

84. The Chronic Conditions-HPI template appears. Chronic Conditions, Review of Systems, Vital Signs, Lab Results, and Medications can be reviewed.

85. The Chronic Conditions-HPI template is a very useful concept—it allows you to document HPI-type history items for chronic medical problems, rather than use an HPI popup that sounds like you just acutely diagnosed the problem. It will be reviewed in detail in another exercise. UNFORTUNATELY, this template is flawed at present, such that it cannot be used in the intended fashion or to its fullest potential. There are a couple of options we suggest.

86. One alternative is to just type your notes in the “Free text” Comments box. You can also use My Phrases to help with that. 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.

87. Note the Protocols and Recommended Care grids. Management protocols can be established for various chronic diseases, and configured for each patient. These topics will be reviewed in another demonstration. When done click Save and Close.

88. Another alternative is to avoid the Chronic Conditions HPI popup, and use a generic HPI popup instead. Instead of clicking HPI Detail, click All HPIs.

89. Select the E-O tab, then click on Generic Free Form.

90. The Generic Free Form HPI popup will be used when NextGen doesn’t have a specific HPI popup associated with the patient’s chief complaints, but it can also be useful in addressing chronic problems. Use the pick lists and bullets to the extent they’re relevant, then type notes similar to those mentioned above in the HPI Comments box. When done, click Save and Close.

91. Next, click Physical Exam.

92. Here you can document most common exam items on all systems. You can click on the link for each individual system, to go to a more detailed exam popup for that system.

93. You can also save and recall personalized exam presets, which can save you time on future encounters. (A review of this will be included in another lesson.) Here we’ve documented several exam findings. When done, click Save and Close.

94. You can add exam comments here; you can also have them carry forward to the next visit. You can document procedures using this button; we will not be performing any procedures during this encounter.

95. If/when the Chronic Conditions HPI popup works correctly, hypertension and diabetes may already be added to today’s assessments. If not, they can be added as illustrated momentarily. We’ll also add bronchitis. Select the next available Assessment bullet, then click Update.

96. You’ll see 3 possible assessment popups. As of this writing, the Custom popup is not in use. Click the Specialty popup.

97. This leads to a list of common specialty- specific diagnoses. Click Bronchitis, acute; it will be added to the Assessment List. When done, click Save and Close.

98. Bronchitis is added.

99. We’ll also add Tobacco Use Disorder. Click the next available bullet, and this time select Standard. (You would also get this if you just clicked in the empty Assessment box.)

100. Click in the next empty Assessments box.

101. The familiar diagnosis search box appears. Type tobacco, choose a search option, then click Search.

102. Double-click on Tobacco use disorder 305.1.

103. Tobacco use disorder is added. Click Add to add Tobacco use disorder to the Chronic Problem List. You can also add selected diagnoses to My List. You can also use My List to quickly add diagnoses in the future.

104. Note that hypertension and diabetes appear on the Diagnosis History and Active Chronic Problems lists. You can click on these, giving you another quick way to add them to Today’s Assessments. When done, click Save and Close.

105. Note that you can rearrange your diagnoses. Click Sort DX.

106. Click the diagnoses on the left in the order you want them to appear on the right. This is particularly useful to avoid having an unreimbursed diagnosis, such as Tobacco Abuse, on the first line. When done, click Save and Close.

107. Now we’ll enter some plans and orders. Click My Plan/Orders.

108. Plans, instructions, lab orders, diagnostic study orders, referrals, etc. are available in a tabbed format. A detailed review of these will be provided in another lesson. The 1st tab, My Plan, will not be the way we order labs or X-rays at present. The one thing you might want to use this for would be to specify follow-up plans.

109. Check the follow-up box, and click the dropdown arrow. Specify follow-up visit in 4 weeks, then click OK. When done, click Place Order.

110. The Plan Details tab is the best spot for you to enter your plan for each problem. You can do this by free-typing or using My Phrases, a very helpful way to insert instructions you frequently repeat. Use and setup of Plan Details is covered in another lesson.

111. We’re not currently using the Labs tab at present. Labs will be placed through the Order Module, which is covered in another lesson.

112. On the Diagnostics tab we’ll order a chest X-ray. First select the Bronchitis diagnosis.

113. Click the X-ray Body dropdown arrow, and select X-ray, chest, two views, frontal/lateral in the popup.

114. Click Place Order.

115. Your chest X-ray order appears on the grid here. You’ll be given the chance to send a task about this to someone, but we’ll just click Cancel. Let’s print a requisition for this X-ray. Counter-intuitively, this is not the easiest spot to do that. Click Save and Close.

116. Go to the Checkout tab.

117. Here you see all the orders you’ve placed. Select the chest X-ray and click Requisition.

118. Click the Printer icon to print this for the patient. When done, close the document and return to the SOAP template.

119. Now we’ll prescribe medications. Click Meds.

120. A detailed review of the Medication Module is provided in another exercise. Here we’ve refilled Cozaar and metformin, and prescribed azithromycin. When done, close the Medication Module.

121. The patient needs a work excuse. Click Document Library.

122. There are links to several document types. Click Work/school excuse brief.

123. We’ll excuse him for 2 days. When done, click Save and Close.

124. The work excuse document displays. You may further edit the text as desired, then click the Printer Icon to print the excuse. When done, close the document by clicking the X.

125. We don’t need to generate anything else from here, so close the Document Library by clicking the X.

126. Note that, if you display the History Bar, you can also access all available document templates in a tab by clicking on the Document Module here.

127. This opens a search window. Type Ex, and you’ll scroll forward and see ExcuseNote. Double-click on that.

128. A basic excuse note appears, which may be preferable to you than the one generated above. Edit as necessary and print. When done, close the document.

129. You can also use this to create a letter. Start to type let…, and the display will scroll to this screen. Double-click on Letter_Generic.ngn.

130. A simple letter format is produced (our letterhead will be added). Type text as desired, print, then close the letter.

131. Now generate today’s visit note. One way to do this would be to click Chart Note.

132. Your visit note displays. However, this will generate the note in real time, which can tie up your computer for several seconds, or even minutes.

133. So you’ll probably want to generate the note offline. To do this, hover the mouse over Navigation. When the Navigation Bar displays, click Offline.

134. Now move to the Finalize OV tab. E&M coding is reviewed in another lesson. For this exercise, click Moderate complexity for Medical decision making, then Calculate Code.

135. If the calculated code is acceptable to you, click Submit Code(s). Residents will need to click Submit to supervising physician for review.

136. Select your attending, then click Add User(s). Then click OK.

137. A resident also needs to view encounter properties to set the Supervising Physician for billing purposes. Right-click on the encounter folder and select Properties.

138. The resident doctor clicks the Supervisor dropdown arrow, and selects the attending. In this example, we’ll use Dr. Duffy.

139. Click OK to close the popup.

140. One of the Meaningful Use criteria requires patients to receive a summary of their visit. Click Patient Plan.

141. A visit summary is produced (our letterhead will be added). Edit the text if desired, print, then close the document. The provider’s work is complete, and the patient can be sent to checkout, or further work can be completed by the staff as necessary.

142. The Checkout tab may be utilized by office staff to document completion of various orders, referrals, appointments, etc. The degree and manner of its use will be individualized to the workflow of each clinic.

143. This concludes the NextGen Adult Visit demonstration. How do they get the deer to cross at that yellow road sign?

144. This concludes the NextGen Adult Visit demonstration. How do they get the deer to cross at that yellow road sign?