Prepare for the Back-to-School Physical Exam Rush with These 6 EHR Workflows

August 7, 2018

Back-to-school season is a busy time for everyone. Teachers are whipping their classrooms into shape, parents are getting their children equipped to excel, and physicians are trying to juggle the mad rush of back-to-school physicals, vaccinations, and boosters.

Thankfully, the NextGen electronic health record solution has several simple workflows to streamline back-to-school checkups and maximize your time.

Here are six ways NextGen EHR workflows can make back-to-school check-ups a breeze. Stay tuned to the end for our downloadable guide.

John Lynch & Associates back to school physical exam check up EHR workflow

Make the Most of Your KBM for School Physicals

Within the NextGen EHR, you will find what is called a Knowledge Base Model, or KBM for short. This KBM is a template that comes standard with your NextGen EHR solution and allows you to collect all the pertinent information you need for each client.

Never worry about forgetting a detail or missing a crucial piece of information schools need to complete their records.

Here’s how:

The Workflow

First, ensure the Urgent Care specialty is configured properly to best utilize the KBM when completing a school physical.

1. Access NextGen Ambulatory EHR and open the Workflow module.

2. Open your patient’s chart and be sure to complete the 4-point check.

3. Click Templates Icon and double-click *Home Page template

4. From the Specialty list, select Urgent Care.

5. From the Visit Type, select School Physical

Streamline Documenting Patient Details

There is a certain set of patient information you will need to collect during each visit. Details such as vital signs, allergies, medications, and the reason for the visit cannot go undocumented.

This workflow will ensure you get the necessary information into each patient’s EHR in record time.

The Workflow

1. Click the Intake tab and expand the General panel.

1. Select Established Patient or New Patient.

2. Click Historian and select the relationship of the historian.

2. Expand the Reason for Visit panel.

1. Select the patient’s chief complaints.

2. Select HPI (History of Present Illness) details.

3. Document Intake Comments, if applicable.

3. Expand the Vital Signs panel.

1. To document a new vital sign, click Add

4. Expand the Medications panel.

1. To add or update medications based on the patient’s current medication list, click Add/Update.

2. Select Summary of care received, No medications in encounter, and Medications reconciled, if required.

5. Expand the Allergies panel.

1. To add new allergies, click Add. If the allergy is not listed, go to the Allergy module to add it.

2. To document comments, click Comment.

3. Select No known allergies, Reviewed, updated or Reviewed, no changes as applicable.

6. Expand the Orders panels.

1. If an in-house test is needed at this time, click Standing Orders to order and document diagnostic history details.

2. Click Lab/Radiology Order Processing, Order Management, Immunizations and Tasks and documents as applicable.

7. Expand the Review of Systems panel and document ROS and click Generate Intake Notes to generate an intake note.

Patient Histories Made Easy

This workflow makes it fast and easy to collect complex patient histories while ensuring no critical information is overlooked.

The Workflow

1. Click the Histories tab and review the details.

2. Expand the Problem List panel.

1. To launch the Problems Module and add new clinical problems, click Add.

3. Expand the Medical/Surgical/Interim panel.

1. To input new medical and surgical history details, click Add.

2. To input information about hospital stays, ER visits or important encounters that have occurred, click Interim History

4. Expand the Diagnostic Studies panel.

1. Select the patient’s chief complaints.

2. To document important diagnostic studies, click Add.

5. Expand the Family panel.

1. To input relevant family history details, click Add

2. If there is nothing to document, click No Relevant Family History.

3. Click Adopted – No Family History Known if this applies to the patient.

6. Expand the Social panel.

1. Select the section that needs to be documented.

2. To input new information, click Add.

3. To add details those are confidential, click Confidential History.

7. To determine the level of detail that should be included in the final document for this encounter, click History Review at the top of the template.

8. To generate intake note, click Intake Note.

Speedy SOAP Notes

Thanks to Lawrence Weed, MD, medical professionals have relied on the comprehensive SOAP note format to document patient visits since the 1970’s. Now, the time-tested SOAP note format is at your fingertips in the NextGen EHR.

Here’s how to put that workflow to use:

The Workflow

1. From the SOAP tab and expand the Reason for Visit panel.

2. To document new or updated HPI details, select any existing chief complaints listed in the grid and enter the details.

3. Add any new chief complaints for the patient.

2. Expand Review of Systems panel.

1. To document details for all systems, click Urology-ROS.

2. To add specific details to one system at a time, click each individual system.

3. Expand the Vital Signs panel.

1. Review vital signs added during this encounter.

2. To input new information, click Add.

3. To modify vital sign details, select a vital signs entry, and then click Edit.

4. Expand the Physical Exam panel.

1. To document details for all areas of the body, click Additional and select One Page Exam.

2. To input details specific to one area at a time, click each exam template and select the details.

5. Expand the Assessment/Plan panel.

1. To add or update assessment details, click Add/Update.

1. To input all assessments for the visit, click Assessments.

2. To create orders for each assessment, select the My Plan tab.

3. To create orders, click Labs, Diagnostics, Office Procedures, and Referrals and document the order details.

2. To put the patient on a health promotion plan, click My Plan tab, click Health Promotion Plan and then document the health promotion plan details.

3. To schedule any procedures for the visit, click the Procedures Scheduling button.

Sign-Off, Finalize & Generate Notes

Physicians are required to sign off on dozens of documents each day. During back-to-school season, there is even more paperwork to finalize.

The NextGen EHR makes signing-off, finalizing, and generating completed patient notes a quick and simple process.

The Workflow

1. Click the Finalize tab.

2. Verify that all assessments are added to the Today’s Assessment panel.

1. To document any assessments that were missed, click Add.

3. Expand the Provider Sign Off panel and choose the physician sign off option if a supervising physician is required for sign off purposes.

4. Expand the Evaluation and Management Coding panel.

1. Select the complexity of medical decision making.

2. To determine the E/M Code based on documentation, click Calculate Code.**If a different code other than the calculated code is needed choose the code from the available fields before clicking Submit Code.

3. To submit the codes to the procedure module and PM system, click Submit Code.

5. Generate the Master Document.

1. Based on the configurations, the Master Document is generated when the code is submitted.

2. If the document is not automatically generated, click Generate Note, select Master Documents, and click OK.

3. To generate additional documents, click Generate Note and select the document type.

Forward-Thinking EHRs

Not only do physicians need to evaluate patients and document their every detail, but also they are required to document communications with patients, including any orders given or plans made.

Within the NextGen EHR system, physicians can quickly make note of patient plans and orders so they are easy to find for follow-up appointments and school records.

The Workflow

1. Click the Checkout tab and expand the Today’s Orders panel.

1. Select the order type from the list.

2. All the displayed order types have specific options and details to complete. Note the buttons and options that appear when each order type is selected.

3. Document any orders that are complete or updated.

2. Expand the Given to Patient/Verified panel.

1. Document any items that were given to the patient.

2. To generate the patient plan, click Patient Plan.

Click here to download our printable NextGen School Physical Workflow Defined.

Have questions about how NextGen workflows can help you check all the boxes during back-to-school season? Let us know!