Transcript NEXTGEN PRENATAL INTAKE VISIT DEMONSTRATION

NEXTGEN NURSE VISIT
(OBGYN)
DEMONSTRATION
This demonstration reviews examples of nurse visits
using the OBGYN templates.
This has been prepared with EHR 5.6.5.61 and KBM
7.9.1. Subsequent updates may display cosmetic and
functional changes.
Use the keyboard or mouse to pause, review, and
resume as necessary.
There is no audio with this exercise.
Example 1: Pregnancy Test
In this example, a patient comes in for a
pregnancy test. This will be completed by
the nurse.
The nurse opens patient’s chart. If
necessary, display the History Bar and create
an encounter for today by clicking New.
Select OBGYNHome. (This will
be among the
recommended
preferred
templates at
setup.)
If the OBGYNHome template
does not display
spontaneously,
click the
Template Module.
If necessary, select New vs Established patient.
Select visit type
of Nurse Visit.
Select your provider, e.g., the clinic supervising
attending that day.
(The nurse is likely working with several
providers at a time, so it is important to
confirm this selection from patient to patient.)
Patient
Location
Provider
Date
Perform the 4-Point check.
Click in the first Reason for
Visit box, select the blank at
the top of the list, then type
Pregnancy test.
It is often clinic policy to record some vital signs at
nurse visits.
Right-click on the Vitals grid and select Add new.
Record vital signs.
When done, click Save, then Close.
Vital signs display in the grid.
Perform the urine pregnancy
test, then go to Nurse Doc.
Click Office Diagnostics (sometimes
labeled “Office Services”).
Click in the Display order set
box and select Office Tests.
Scroll down the list until you see the line for Urine
pregnancy test associated with the diagnosis of
Scanty or infrequent menstruation 626.1.
Click on this.
The test, associated with this diagnosis, appears here.
If you don’t see the test associated with a
satisfactory diagnosis, you can click Add
or Update Assessment.
You’ll probably see the diagnosis you
need on one of the lists here; if not,
you can use the available methods to
search for it.
When done, click Save and Close.
If there is a test/diagnosis combination that is
frequently used that you don’t see on the Office Tests
order set, notify the EHR Team, so that they can add it.
Enter the result in the Detail box.
Click Submit to Superbill,
then Place Order.
When done, click Close.
Inform the patient of the result, and send
her to checkout.
Display the Nav Bar if necessary, and click
Offline to generate a brief note
documenting this visit. (You could click
Preview to generate the note in real time,
but it could take several moments,
preventing you from moving on to other
work.)
Example 2: Depo-Provera Shot
In this example, a patient comes in on
schedule for her Depo-Provera injection.
The nurse opens patient’s chart. If
necessary, display the History Bar and create
an encounter for today by clicking New.
Select OBGYNHome. (This will
be among the
recommended
preferred
templates at
setup.)
If the OBGYNHome template
does not display
spontaneously,
click the
Template Module.
If necessary, select New vs Established patient.
Select visit type
of Nurse Visit.
Select your provider, e.g., the clinic supervising
attending that day.
(The nurse is likely working with several
providers at a time, so it is important to
confirm this selection from patient to patient.)
Patient
Location
Provider
Date
Perform the 4-Point check.
Click in the first Reason for
Visit box, select the blank at
the top of the list, then type
Depo-Provera.
It is often clinic policy to record some vital signs at
nurse visits.
Right-click on the Vitals grid and select Add new.
Record vital signs.
When done, click Save, then Close.
Vital signs display in the grid.
Give the injection, then go to Nurse Doc.
Click Office Diagnostics. (Obviously, a Depo-Provera
shot is not a diagnostic study, but you’ll see where
we’re going in a minute. In some places this will have
the more appropriate label of “Office Services.”)
Click in the Display order set
box and select Office Meds.
Scroll down the list until you see the line for DepoProvera associated with the diagnosis of
…Contraceptive management V25.09.
Click on this.
Click Place Order.
The injection appears on the Today’s Orders
grid. Double-click on this.
Click Completed.
Click in the Admin/other 1 box, and select
Ther/Proph/Diag Inj, SC/IM in the popup.
If you don’t see the administration code on this
popup, you can click the Dropdown Arrow to search
for other codes.
Click Submit to Superbill. Text confirms
the submission of the injection and the
administration code.
When done, click Save, then Close.
Click Close again here.
Send her to checkout, if you haven’t already.
Display the Nav Bar if necessary, and click
Offline to generate a brief note documenting
this visit. (You could click Preview to generate
the note in real time, but it could take several
moments, preventing you from moving on to
other work.)
This concludes the NextGen
OBGYN Nurse Visit
demonstration.
If the #2 pencil is the most popular, why is it still #2?
This concludes the NextGen
OBGYN Nurse Visit
demonstration.
If the #2 pencil is the most popular, why is it still #2?