Physician Best Practices - Using Addendums in NextGen Ambulatory EHR…ezoutlook.com/userarea/Physician_Best_Practices_Using... · 2014-02-05 · Confidential – Proprietary Information

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Physician Best Practices - Using Addendums in NextGen®

Ambulatory EHR, Version 5.8

www.nextgen.com

http://www.nextgen.com/

Using Addendums

Confidential – Proprietary Information – For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. Published: November 2013.

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After a period of time, encounters are generally locked. The decision when to lock encounters is made by the practice. The information contained in the locked encounter is read-only and cannot be altered. Sometimes, however, a provider receives additional information on a patient they want to add to the patient’s chart. There are two options for adding information to the patient’s chart.

One option is to open a new encounter for today, select Chart Update for the type of visit, and add the additional information to a "new visit".

The second option is to add a note to the previous visit. In order to add a note to a locked encounter, it is necessary to add an "addendum" to the locked encounter.

There are three Addendum types in NextGen Ambulatory EHR.

One is the Addendum folder that a provider opens up for a locked encounter.

The second Addendum is a document, on which a provider can type in information they want to put into the patient’s chart. The Addendum document can also be used for an unlocked encounter to enter additional information the provider received after generating the visit note.

The third type of Addendum is an addition to a document that has been electronically signed in an unlocked encounter.

Adding an Addendum to a Locked Encounter An addendum folder can only be added to a locked encounter.

In this case, the encounter for 8/6/12 is locked.

Rather than add the additional information to today’s visit, the provider would like to add the information about previous biopsies done elsewhere to the 8/6/12 visit.

To add information to an encounter 1 Highlight the 8/6/12 encounter in the encounter/history toolbar.


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2 Click File > New > Addendum to add an Addendum folder to this locked visit.

If an unlocked encounter is highlighted, the option to create a new Addendum folder is not available. (It is grayed out). A warning opens to verify a new Addendum folder should be added.

3 Click Yes.


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A new Addendum folder opens.

In the screen shot above, there is a new folder icon with a paper clip attached within the 8/6/12 visit. When the history encounter bar is refreshed, the addendum folder displays as follows, with the original encounter date in parentheses and the date of the actual entry following.

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When the Addendum folder is created, only documents or images can be added to the folder.


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With the Addendum folder highlighted, only the Documents icon and the Images icon are selectable from the History toolbar.

4 Click the Documents icon on the Patient History toolbar to open a list of documents that can be

generated.

One of the documents listed is the Addendum document. This is a nearly blank document that can be used for entering free-text that is often chosen to place in the Addendum folder.

5 Highlight the name of the Addendum document and click the Generate button.


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An addendum document is generated where the provider can enter free-text information. Notice that the header clearly states the addendum belongs to the 8/6/12 visit but is being generated on 9/30/13.

Above, biopsy results have been entered as free-text.

6 When done, save and close the document.


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Now, in the Patient History (encounter) toolbar the addendum document displays in the 8\6\2012 folder.

If You Forget to Generate a Document Sometimes the provider has forgotten to generate a document for the encounter and this goes unnoticed until the patient returns for a follow-up visit. Although the provider may go through the templates to figure out what happened during the visit, it is easier to read the information from a document.


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For the 9/27/13 visit, no document was generated and the visit is now locked. To generate a document for the 9/27 visit, an Addendum folder can be created.

1 Go to the History toolbar and click the Documents icon.

2 Select the name of the document that was not generated (in this case, the Master_Im document). 3 Click the Generate button.

This generates the master document:


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Note: The day the encounter took place is in parentheses, and the date and time the document was generated follows. When the document is saved, it displays within the Addendum folder:

Note: You must know the title of the document to generate it.

Signing off on Encounter Notes when the Encounter is Locked: Sometimes when a provider tries to sign off on a note written by someone else, the encounter for that note is already locked. There are two ways to sign off on this note.

One way is to unlock the encounter, and thereby get access to the note to sign off. Some practices do not permit providers to unlock encounters.

A second way is to create an addendum folder for the locked visit, and then from the Documents icon select the name of the document you want to sign off on. Click the generate button. (See previous section with screen shots). Once the note is generated, you can type a line at the bottom indicating that you reviewed and agree with the above note. Alternatively, the note can be signed and an addendum can be added at the bottom of the note.

Adding Addendum Notes to Unlocked Encounters Sometimes you have finished your note for an encounter, and one hour later you get additional information you want to add to the chart. You don’t want to bother going through the templates again and regenerating your document. Instead you can add a document to your unlocked encounter.


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In this case, an entire Urology visit was completed and the document was generated. However, now there is additional information to add to the record.

To add additional information to the completed visit 1 Highlight the visit. 2 Click the Documents icon. 3 Select Addendum. 4 Click the Generate button.

The Addendum document is generated, and you can enter free-text information.

Note: The date and time of the initial visit, as well as the date of the Addendum document are written in the header. At the bottom of the document is a notation indicating who generated the document and when (date and time). This Addendum document should not be used to enter data that might need to be reported on. This Addendum document is not in an Addendum folder. It is in the unlocked encounter for today. The disadvantage of using an Addendum document, in this case, is if there is another document in that day’s encounter, the important information in this addendum document may be overlooked.

Adding an Addendum to a Document in an Unlocked Encounter Sometimes a patient leaves the office, a note is finalized, and then something happens on the way out. Addendum notations can be added directly to documents that have already been electronically signed –in encounters that are still unlocked. These notations are date and time-stamped, with the logged-in user’s name attached.


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When the visit note document is generated, there is a blue check mark in the upper right corner of the document:

When the blue check mark is clicked, the check mark symbol changes to a paper clip symbol.

To add an addendum to a document 1 Click the paper clip symbol to open an addendum window at the bottom of the document.


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An Addendum field opens at the bottom of the document. When information is typed into the Addendum field, two icons become visible on top of the field to the right:

The icon resembling a garbage can deletes this addendum note. The icon with the green circle saves this addendum note and adds it to the bottom of the previously-completed and signed note.

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2 Click the green circle. The Addendum notation is seen below the note, dated, timed and with the logged-in user’s name.

3 Click the paper clip symbol at the top right of the document to add another addendum. Different users can add an addendum to the document if needed. As many addenda as needed can be added, as long as the visit is unlocked.