1. NEXTGEN PAST MEDICAL, SOCIAL, & FAMILY HISTORY DEMONSTRATION This demonstration reviews documentation of most everything you can enter on the Histories Tab in NextGen. This has been prepared for EHR 5.7 and KBM 8.1. Subsequent updates may display cosmetic and functional changes. Use the keyboard or mouse to pause, review, and resume as necessary.

2. The Histories tab is where most all past medical, social, & family history is entered. At the top are 2 lists: Chronic Conditions & Medical/Surgical/Interim. Ongoing problems big or small go on the Chronic Conditions list. Episodic items go on the Medical/Surgical/Interim list. To add something to the Chronic Conditions list, click Add.

3. The diagnosis search popup appears. There are multiple ways to search for diagnoses. You can select one of the system bullets & look for the diagnosis on the pick list that appears. Here we’ll click Eye. A system-specific list appears. If present, double- click on the desired diagnosis. Here we’ll click Unspecified glaucoma.

4. The diagnosis now appears in the Problem box. But let’s say we’d rather it just say “Glaucoma” instead of “Unspecified glaucoma.” Simply click in the Edit description box, & type Glaucoma.

5. Note that NextGen puts in today’s date as the Date of onset, which is probably almost never right. And often the date of onset is not known, or not of particular importance. To address this, click in the Date of onset box. In the calendar popup that appears, select a date if known or pertinent. But if not, just cancel out of it.

6. You can leave the date blank, though you’ll have to click through a nag screen if you do, & there are some potentially troublesome sequelae on down the line. Instead, we suggest entering 11111111 as the date. Use the delete key to remove the date.

7. You can also add some info in the Display comments box; these will have the advantage of showing on the Histories Tab. For more lengthy comments, use the Additional information box. When done, click Save then Close.

8. Your entries display in the grid. To make more entries, click Add again.

9. While the system lists can be useful, they often don’t include items you’re looking for, so you might be better off using one of the 4 search items at the top.

10. Search my most common, as you might expect, brings up a list of diagnoses you use most frequently.

11. Search my list brings up your My List of diagnoses. (Setup of this list is discussed in the User Personalization demonstration.) If you’ve set up your My List, this is often the fastest way to find a diagnosis.

12. Search by code gives you a list by diagnosis code. If you know the code, type the first few digits, & the list will narrow down to those diagnoses that match what you’ve typed. (You also get this popup if you click in the Code box.)

13. Search All is the most versatile of the options. (You also get this popup if you click in the Problem box.) You can search by description or code. Here we’ll search for Hypertension. Type Hypertension then click the Search button. A tip: Of all the search options, Starts With is the worst, since the word you’re searching for may not be the first word in the official terminology.

14. Double-click on Benign essential hypertension to select it.

15. I’ve removed the Date of onset. This time click Save & Add New.

16. This gives you the opportunity to add more diagnoses without closing the popup. I’ll add a couple more things, then click Save & Close.

17. You can modify details about an item on the list by double-clicking on it.

18. Before we go further, there are 3 spots on the problem search popup that people sometimes ask about, but (in my opinion) we don’t really need to deal with. Date…addressed seems to be something that gets automatically date-stamped in some fashion. Resolved doesn’t seem to work in a helpful or intuitive fashion. Add to diagnosis module doesn’t appear to add any particular value to our workflow.

19. Now we’ll add some past medical history. Click Add.

20. You’ll see a popup that gives you the chance to add a lot of common historical items quickly. But note: There are many items here that actually belong on the Chronic Condition list, & not on Past Medical History, where we only want to add episodic items. So don’t add things like depression, diabetes, hypertension, etc. here.

21. But there are several items here that are useful. For example, click the Cholecystectomy checkbox, then select 1997. (If you don’t know the year, you can just close out of the date popup.)

22. Your entry displays. You can then select additional items, which I’ve done here.

23. For items you don’t see on the list, click in the System box, & we’ll document a previous bout of meningitis.

24. Select infectious disease. In the ensuing popup click Meningitis, bacterial.

25. Your entry displays. Add other details as pertinent/desired. You can click Save & Add New if you want to make more entries. When you’re done click Save & Close.

26. You can also add various other interim history items. Click Interim History.

27. We’ve entered that she’s recently seen her eye doctor for a check on her borderline glaucoma. When done, click Save then Close.

28. Your entry appears. Notice that you can click on any column header to sort top to bottom or bottom to top on that header, which can help when viewing a long list of entries.

29. Note that a chronic problem might not be a “chronic problem” forever. You can delete an item from the Chronic Conditions list by right-clicking on it & choosing Delete. As you do that, you might want to make a corresponding entry on the Medical/Surgical/Interim list. For example, if a patient had a colon polyp that was needing early repeat colonoscopies, it would be good to have on the Chronic Conditions list. But if 8 years later you’ve had several normal scopes & it is time to drop to normal colon cancer screening, you’d probably want to change it to an entry on the Medical/Surgical/Interim list.

30. For women, note this link. Clicking on OBGYN Detail brings up the OBGYN Synopsis. You can enter several details directly. To enter pregnancy history, click the Details button.

31. Enter data in the white boxes, & the program will summarize it in the gray boxes. When done click Save & Close. If desired you can double-click on the grid & enter details about each pregnancy.

32. When done click Save & Close to return to the Histories Tab.

33. A little lower on the Histories tab there is a section for Diagnostic Studies. Click Add.

34. Click in the Diagnostic study type box & make a selection from the list. Here we’ll pick MRI Head/spine.

35. Then click in the Diagnostic study,box & make a selection from the ensuing popup. Here we’ll select MRI, lumbar spine, w/ contrast.

36. Fill in other details as known. Here the patient tells us she had a lumbar MRI about 2 yrs ago, showing only mild disc bulging. Beware: There is a gotcha here. Contrary to typical Windows behavior, at various places in NextGen, the program requires you to click the “little save” button—Save & Add New—before clicking the “big save” button—Save & Close. If you click Save & Close directly, it won’t post your entry. There are fewer places this happens than in the past, but, frustratingly, they are still some waiting to bite you.

37. While it’s nice to have a section to record Diagnostic Studies, you probably won’t do this very often. If there is a report available within the USA system, we have pretty quick ways to view those. If the patient has a paper report, you’d probably want the staff to scan it into the chart. So the main time you might use this is when the patient gives you a verbal history of a previous study that you are taking at face value. (Also, the lists on the Diagnostic Studies popup are not particularly complete, so you often can’t find the test you’d like to document.)

38. Continuing down the Histories Tab, under the Family section click the Add button.

39. On this popup you can select a family member & enter positive or negative history of relevant conditions. Here I’ve entered that her father had coronary artery disease & lung cancer, but no diabetes.

40. Note the Age onset or death box. It typically indicates age of onset, but if you click the cause of death checkbox it indicates that it was the cause of death at that age. When done with the father, click Save & Add New to make more entries

41. For relatives other than the ones shown at the top, click in the Other relative box & make a selection from the list. You can also click the blank at the top then type in whatever you need.

42. When done click Save & Add New. If you don’t see the condition you need to document, click the Other Yes (or No) bullet. Make a selection from the list, or free-type your entry.

43. Note that you can select Family H/O to document history on unspecified family members. If you can’t document any details because the patient is adopted, you can select that checkbox. You can also select No relevant family history if that is the case. But it would make a more convincing story if you documented a specific, pertinent negative history, such as a negative family history of breast cancer.

44. Speaking of cancer, when you click the Cancer Yes (or No) bullet, you’ll get a pick list to select or type in the type of cancer. When you’ve made your last entry, click OK.

45. But note: This is another spot where NextGen is fickle about the “little save, big save” convention. We think we’ve gotten this fixed so that just clicking OK on the last entry will reliably post that entry, so you can do that—just make sure your last entry actually displays on the Histories Tab. Or stay in the habit of clicking Save & Add New, then OK.

46. Your entries display on the Histories Tab, & we can continue down to the Social History section. Note: We’ll demonstrate the entry of adult social history in this lesson. Social history for small children differs considerably; that is illustrated in the Well Child Visit lesson.

47. Under Social History you see another set of pilltabs that allow you display various types of social history. But first we need to make some entries, so click the Add button.

48. The Social History popup appears. Note that there are several headings on the left, corresponding to the Social History pilltabs we just saw; we start out on the Tobacco/Alcohol/Caffeine heading. Also note that, since no Smoking Status is recorded, there is a red Required for MU (Meaningful Use) notice. To document this, click either that red notice or Tobacco Usage. Tobacco/smoking history can be a little confusing & redundant in NextGen, so let’s spend a little time on that.

49. The Tobacco Use popup appears. Note there are 2 sections at the top. The 1 st is Tobacco Use. The 2 nd is Smoker Status (Meaningful Use). You need to complete both of these sections. Smoker Status is what appeases the Meaningful Use overlords. But Tobacco Use is more detailed, & lets you record a history of tobacco use over subsequent visits, since people can stop & stop various forms of tobacco over time.

50. If the patient has never used any form of tobacco, it’s simple. Click Never in each section. Click Add to add this Tobacco Use documentation to the Tobacco Use-History grid.

51. For someone who currently uses tobacco, click current under Tobacco Use; fill in other details as known/pertinent. Also click one of the Current options under Smoker Status, then Add.

52. This status is added to the Tobacco Use Grids.

53. If you make a mistake recording tobacco status, click on that line of the Tobacco Use – Current grid, & you’ll see that an Update button appears. Correct your Tobacco Use entries, then click Update. Make sure you also change the Smoker Status if necessary. When done click Save & Close.

54. You’re returned to the Social History popup, with the tobacco & smoking statuses recorded. Your clinic may have a policy that nurses rooming patients always advise tobacco users to quit. If so, the nurse can click the Tobacco cessation discussed checkbox. A sample dialog might go as follows: “Do you still smoke? Of course, we recommend that everyone quit smoking. [Check the Tobacco cessation discussed checkbox.] Would you like to talk to the doctor today about help quitting?” If the answer is YES, add Smoking Cessation to today’s Reasons For Visit.

55. You may notice this Tobacco Cessation link. This leads to a detailed template on which you could more thoroughly document tobacco counseling. But unless the entire visit is for this purpose, you probably don’t want to use this. Moving from tobacco (finally), we’ll indicate that the patient drinks alcohol & caffeine.

56. Enter detail to the degree it is known & pertinent. There are several popups that offer to help you with this, but often it is easiest just to type in a brief entry like this. While you can click Save & Close at any time, let’s move to the Statuses heading.

57. Enter details to the degree they’re known or pertinent. Some demographic info may already display. In particular, note that we need to record language, since it is one of the Meaningful Use criteria. Occupation is a bit redundant, since there is a separate section for that. Note the Pediatric/ adolescent Social History link. This gives you the chance to toggle to & from the pediatric version of the social history—particularly useful for adolescents. It’s a little odd that the Statuses heading is the only place you see it. Now move to Lifestyle.

58. As before, enter as much detail as desired, then move to Occupation.

59. Enter occupational data as desired.

60. The final heading, Comments, gives you a good place to free- type other social history notes. When done click Save & Close.

61. Your entries display on the Histories Tab, depending on which pilltab you select. Now click the Confidential History button.

62. Here you have the opportunity to document other aspects of the social history that are not included on the previous popups.

63. Now perhaps you’re thinking “Isn’t all medical information confidential?” Yes, of course, & many of the issues listed here are things we would commonly ask. A better way to think of this popup is information that is not subject to subpoena. Unless you click the Include all… checkbox, this info won’t be included in your visit note. This is done so you could theoretically generate notes that could be turned over to the court without further review. At USA any requested records are reviewed & redacted as appropriate; since information here is often necessary for thorough documentation of a visit, feel free to include this in your visit notes as appropriate.

64. Note that information you’ve entered via Confidential History doesn’t display on the Histories Tab; you’ll have to click the Confidential History button again to see it.

65. A couple final things. We just recorded a history of smoking, so let’s go back to the Chronic Conditions list & add Tobacco Abuse 305.1, since that is arguably a very pertinent chronic medical problem. Also note the Tobacco Risk Indicator is now activated, since we recorded this in the Social History. Click the Configure link to complete the other Risk Indicators.

66. Tobacco has already been addressed. Sometimes the other risk indicators will also be answered “yes” automatically if those diagnoses are previously documented on the Chronic Condition List or earlier encounters, but this doesn’t work 100% of the time, & no entry will be pre-populated as “no.” So this will require some manual configuration the first time & on any subsequent change. Click the bullets for Hypertension Yes, Diabetes Yes, & Coronary Artery Disease No. When done click Save & Close.

67. This concludes the NextGen Past Medical, Social, & Family History Documentation demonstration. A conclusion is the place where you got tired of thinking. R. Lamar Duffy, M.D. Associate Professor University of South Alabama College of Medicine Department of Family Medicine

68. R. Lamar Duffy, M.D. Associate Professor University of South Alabama College of Medicine Department of Family Medicine This concludes the NextGen Past Medical, Social, & Family History Documentation demonstration. A conclusion is the place where you got tired of thinking.