Section 12E: Procedures Page 1 of 6

Section 12e: Procedures Page 1 of 6

PROCEDURES

(REMINDER: When you document on a procedure note, please remember to choose an appropriate diagnosis for the procedure you had performed. Without the diagnosis, the procedure notes will not generate on the Master IM document.)

(Also, please NOTE: Do not use the Submit to Superbill button in any of the Procedure Templates after the patient has left.For example, if one does not finish his/her chart and goes in later to complete, he/she should not send charges across as they most likely are already entered on the account.)

1.  The Procedure (AHN2_Procedures) Template is divided up into eight categories (ENMT; Biopsy/Aspiration; Gastrointestinal; Skin & Nails; Pulmonary; Neurological; Genitourinary; and Other).

2.  It also has an area (Pre-Procedure Care) where you can capture that consent was obtained; procedure/risks were explained; and questions were answered as well as generate a Procedure Consent form after completing the Consent template.

3.  In addition, there is a grid area in which procedures performed will be listed and a grid area that displays the status of tetanus shot.

4.  Finally there is a Comments section that when filled in will get displayed on the Master_IM document.

EXAMPLES OF PROCEDURE TEMPLATES

Wound Care Instructions:

1.  Click on the Wound Care/Suture Removal active text link in the Skin & Nails area to open the Wound Check/Suture/Staple Removal (Proc_Sut_Removal) pop-up template (see image above).

2.  Check the appropriate data.

3.  Click the OK button to save the changes and close the pop-up template. Or, click the Cancel button to discard the changes and close the pop-up template.

Dexa Scan:

1.  Click on the Dexa Scan active text link in the Other area to open the DEXA Result Summary (AHN2_Dexa_Scan_Results) pop-up template (see image below).

a.  Right-click in the DEXA Result Summary grid area.

b.  From the command menu, choose Add New.

The DEXA Results (AHN2_RHE_DXA_Result) extended pop-up template will open (see image below):

i.  Complete the information on the template as appropriate.

ii. Click the Save button to save the changes.

iii.  If there is another DEXA Result to be added, click the Clear for Add button to clear the template then add another DEXA Result.

iv.  Remember to click the Save button after each new DEXA Result information completed.

v. Click the Close button to close the extended pop-up template and return to the DEXA Result Summary (AHN2_Dexa_Scan_Results) pop-up template where you should see the DEXA Results displayed in the DEXA Result Summary grid.

2.  Click the OK button on the DEXA Result Summary (AHN2_Dexa_Scan_Results) pop-up template to save the changes, to close the pop-up template, and to return to the Procedure (AHN2_Procedures) template.

3.  To generate the DXA Report (ahn2_dexascan_documentation) document, click on the Print button next to the Dexa Scan active text link.

A printed copy of the information from the template is then generated into a document format (see image below) which may be printed out if desired.

a.  To print the document, click on File on the menu bar.

b.  Then, click on Print on the command menu list.

Dexa Scan:

Using the Dexa Scan Document (ahn_dexascan_documentation.ngn):

For Providers who would prefer to document their Dexa Scan procedure either by typing or dictating into a document rather than using the Dexa Scan template, there is a document entitled ahn_dexascan_documentation located in the Documents Module for this purpose.

1.  First, in order for the practice address and provider name to generate on the ahn_dexascan_documentation document, a copy of the ahn_master_im template must be available in the History Toolbar for the current encounter folder. If the ahn_master_im template is not yet available for the current encounter, open the ahn_master_im template and click the Save icon button on the Top Tool Bar to save it. If the Save icon button is not available on the Top Tool Bar, close the ahn_master_im template, and then save it whether or not changes were actually made so that a copy of the ahn_master_im template gets saved to the current encounter folder. If a copy of the ahn_master_im template is already available in the History Tool Bar for the current encounter, then you may proceed to the next step to access the ahn_dexascan_documentation document.

2.  Accessing the Dexa Scan Document

a.  To access the ahn_dexascan_documentation document first make sure that the History Tool Bar is open.

b.  Then, go to the Tic-Toe-area of the EHR’s History Tool bar located on the bottom right-hand side and click on the Documents Module icon button (see icon outlined in red on image below).

You will then be prompted with the Generate a Document window.

c.  Scroll through the list and select the ahn_dexascan_documentation document (*.ngn). After selecting the document, click the Generate button.

The ahn_dexascan_documentation document is now open for you to chart in:

d.  Be sure to click the line at which you would like to place your cursor at to begin your typing or dictation. Type or dictate your Dexa Scan results into the document.

e.  Click the Save icon button on the Top Tool Bar to save your information.

f.  Your saved document will then file into your PAQ where you may click the Accept button to sign off on the document and to file it away from the PAQ list.

Adapted from: NextGen EHR User Guide, Version 5.6.7.12 Created: CB 2_2005 Modified: JJ 10_2011