NEXTGEN KBM 7.9 WORKFLOW DEMONSTRATIONSick Child Visit

(Pediatric Template Set)

This demonstration works through a sample sick child visit (asthma exacerbation) in KBM 7.9, introducing the new user to the general workflow. While it uses the Pediatric Template Set, use of the Family Medicine Template Set would present very few differences.

This has been prepared with EHR 5.6.x and KBM 7.9.x. Subsequent updates may display cosmetic and functional changes. Slides are updated if the changes are pertinent to the points being illustrated.

Use the keyboard or mouse to pause, review, and resume as necessary.

There is no audio with this exercise.

The nurse begins by right-clicking on the patient from her provider’s appointment list, and selecting Go to Patient’s chart. (Alternately you can just double-click.)

Our patient is 10 year-old male, established in the practice, brought in for an asthma flare-up.

If this is the first encounter in NextGen, you may see an alert like this. Click OK.

The chart opens to the nurse’s default template; in Family Medicine and Pediatrics, this will be the Intake-OV template. (If the patient has had a previous encounter in NextGen, the chart may open directly to this template.)

Perform the 4-Point check.

Patient

Location

Provider Date

If necessary, select New vs Established Patient. In this example, our patient is Established.

Enter Template set, Visit type, and Historian.In this example, we’ll use Pediatrics, Office Visit, and Mother, respectively. (We could also choose Family Practice for the Template set.)

Glance at the Alert button. If there were any alerts on this patient, the button would change shape and turn red.

Also look at the Sticky Note link. Since the diamond is solid, there is something entered here, so click on this link.

Review the notes. When done click Save and Close or Cancel.

Now click Add to add Vital Signs.

Enter Vital Signs. (Details are reviewed in a separate exercise.)

Data used in this example:

Ht 53.5 inches, measured today.Wt 69 lbs, dressed without shoes.T 98.2, ear. BP 102/60 sitting, right arm.HR 98, regular. Resp 20.Pulse Ox 90%, pre-treatment.

If desired, click the Standard to Metric button to perform this conversion. (Make entries using all English or all Metric units before clicking the appropriate conversion button.)

BMI and the Height, Weight, and BMI percentiles are automatically calculated.

When done click Save and Close.

The patient’s asthma is a known chronic problem.To add that, click Add Problem.

There are multiple ways to search for problems.For this example, click All to search for this diagnosis.

The familiar search popup appears. Using the method of your choice, search for asthma. In this example, we’ll select Asthma 493.90. Double-click on that line.

The diagnosis is displayed.

Enter Date of onset and Additional information to the extent known/pertinent. Asthma was first diagnosed about age 5; we’ll approximate as 1/1/2006.

Click Save and Add New if you have other diagnoses to add.

That’s the only chronic problem we have to enter, so click Save and Close.

The cursor will still be in the Date of onset box. Just type 11111111, then save your entry as described above.

A Note About Date of OnsetNextGen sometimes makes this a required field. However, there are many times when you will be entering data such as this, but won’t know the Date of Onset, and may not have the patient available to ask. Our recommended workaround is to enter the date 11/11/1111.Click in the Date of onset box. This brings up the Calendar popup. Click the X to close it.

Enter medications. You can open the Medication Module by double-clicking on the Medication Grid.

If you display the History Bar, you can also bring up the Med Module in a tab by clicking on the Med Module here.

A detailed discussion of the Medication Module is included in another lesson.

In this example, our patient is taking:Albuterol HFA inhaler 2 puffs every 4 hours as needed.Flovent-44 HFA inhaler 2 puffs twice daily.

Add these medications, then close the Med Module.

Review allergies. He has problems with beets, so double-click on the Allergies grid.

Add the patient’s moderately severe vomiting when confronted with beets. (A detailed discussion of the Allergy Module is covered in a separate exercise.)

When done, click the X to close the Allergy Module.

Beets now display in the Allergies grid.Since this was just added, click the Allergies added today bullet.

Now we’ll add some chief complaints. Click in the 1st Reasons for Visit box.

Select asthma.

Depending upon office policy, the nurse may document some components of the HPI.Click HPI Detail.

A suggestion is for the nurses to document the details in the blue shaded area at the top, and any other information that is volunteered while rooming the patient.The father states this asthma attack started 3 days ago; albuterol has helped, but the attack is moderately severe and worsening. He’s been having a lot of cough; OTC cough meds haven’t helped.When done click Save and Close.

The nurse can add other comments by clicking Intake Comments.

Type comments as desired, then click Save and Close.

The diamond by Intake Comments becomes solid, indicating that something has been entered.

Now move to the Histories tab.

The nurse reviews/enters Past Medical/Surgical history. Episodic historical items should be entered here. Since asthma was entered in the Chronic Problem List, it doesn’t need to be added again here.He’s had no surgery or other major incidents, so click No relevant past medical/surgical history.

To enter the Family History, click the Update button.(Double-clicking the grid would give you an alternate method of entry.)

His mother has asthma.Click the Mother bullet, then the Asthma Yes bullet.

Click Save.

In a similar fashion, add that the sister also has a history of asthma.When done click Save and Close.

Some Social history can be added here.We’ll add that the parents are married, they speak English, there is no smoke exposure, and he is in the 4th grade.

To add further details, click Update.

Add further details.He lives in a suburban house with both parents. He has a younger sister. There are no concerns about how he gets along with family and other children. He’s in the 4th grade. He always wears seat belts. They have smoke and carbon monoxide detectors in the home.

The patient is ready for the provider.Hover the mouse over the Navigation Bar area, and click the Tracking icon.

In the Room box, enter Exam 2.In the Status box, enter waiting for provider.

Click Save and Close.

Patient

Location

Provider Date

The provider then opens the chart from the appointment list and performs the 4-point check, as previously demonstrated.

The Summary tab is NextGen’s recommended starting point for the provider (though the provider can set preferences to begin on another tab as desired).

Chronic problems, vital signs, meds, allergies, and growth charts can be reviewed here.

Begin by taking note of any Alerts, Sticky Notes, or Intake Comments that have been entered. The solid diamonds indicate that there are Sticky Notes and an Intake Comments added.Click on these to review; dismiss the popups when done.

Click in the Order view box. Note that while it initially displays vital signs, several other items can be displayed here.

You will also want to review the Histories tab.

Review/update Past Medical/Surgical, Family, and Social Histories, selecting the appropriate review bullets.

When done, move to the SOAP tab.

Review the Reasons for Visit.With the asthma bullet selected, click HPI Detail.

Review the details entered by the nurse, and add further details obtained from the patient and father.

The father states this asthma attack started 3 days ago, after spending the night with a friend who has a cat. Albuterol has helped, but the attack is moderately severe and worsening. He’s been having a lot of cough; OTC cough meds haven’t helped. There has been no fever. He’s also having a lot of sneezing, runny nose, and watery/puffy eyes. In fact, he has these symptoms a lot. The school says he has to use his albuterol almost every day now, and he’s missed PE several times in recent weeks.

When done, click Save and Close.

Now click Update to address the Review of Systems.

These details display.

Some items that have been previously entered through the HPI may appear here. Add other items as per your normal practice and as dictated by the visit.Here we’ll add that there has been no vomiting, diarrhea, or rash.

When done, click Save and Close.

Next, click Physical Exam.

Here you can document most common age-appropriate exam items on all systems.

You can click on the link for each individual system, to go to a more detailed exam popup for that system.

Here we’ve documented several exam findings:He is in mild distress. There is clear eye, nasal, and postnasal drainage. He displays moderate, diffuse wheezing and slightly labored breathing. Exam otherwise normal.

You can also save and recall personalized exam presets, which can save you time on future encounters. (A review of this is included in another lesson.)

When done, click Save and Close.

We’ll give the patient an albuterol treatment. Click Procedures and choose Nebulizer treatment in the ensuing popup.

Click in the Indication Description box and choose Asthma Exacerbation 493.92 in the ensuing popup.

Select Albuterol premixed 2.5 mg.

Then click Save and Close.

Ask your nurse to do the albuterol treatment. After the treatment is done, return to the Nebulizer treatment popup.

You examine the patient and note a good response. Document this.

Click Submit to Superbill, then Save and Close.

Add today’s assessments. There are several ways to go about this. In this example, click the Update button and select Specialty.

Click Asthma, exacerbation.

It is also likely the patient has Allergic rhinitis, so select this too.

When done, click Save and Close.

These diagnoses now display. Since Allergic rhinitis belongs on the chronic problem list, we’ll add it there.Click in one of the Assessment boxes.

Note that this popup gives you a different way to add diagnoses. We don’t need to select any more diagnoses, but click the Chronic List Add button next to Allergic rhinitis to add it to the Chronic Problem List.

When done, click Save and Close.

Now we’ll document our plans.Click My Plan/Orders.

Plans, instructions, lab orders, diagnostic study orders, referrals, and office services/procedures are available in a tabbed format, though the main tabs we use here are Plan Details, Diagnostics, and Referrals, and to a limited extent, My Plan.

Detailed reviews of these tabs are provided in other lessons. A few simple examples will be shown for the purposes of this exercise.

On the Plan Details tab you can enter plans and instructions here via typing, Common Phrases, or My Phrases. Here we’ve added some instructions and plans for asthma, including the addition of Singulair.Details on the use of the My Plan and Plan Details templates are covered in another exercise.

When done, go back to the My Plan tab.

Highlight one of the Asthma diagnoses.

Click in the He is to schedule a follow-up visit box, and choose 4 weeks in the Timeframe box, then OK.

Finally, click Place Order then Save and Close.

He needs refills on albuterol and Flovent, and we added Singulair and loratadine, so click Meds.

A detailed review of the Medication Module is provided in another exercise.Here we’ll renew Albuterol and Flovent, and prescribe Singulair. Even though we recommended getting loratadine OTC, we’ll add that here as well.

For an actual patient, we would highlight Albuterol, Flovent, and Singulair, then click ERx to electronically prescribe them.

(That can’t be performed in these exercises.)

When done, close the Medication Module.

The patient needs a school excuse.Click Document Library.

There are links to several document types.Click Work/school excuse brief.

We’ll excuse him for 3 days, and keep him out of PE for the next 5 days.When done, click Save and Close.

The school excuse document displays. You may further edit the text as desired, then click the Printer Icon to print the excuse.

When done, close the document by clicking the X.

We don’t need to generate anything else from here, so close the Document Library by clicking the X.

The final Comments box is a good place to add notes about discussions with attending, or the participation of medical students.

One of the Meaningful Use criteria requires patients to receive a summary of their visit. Click Patient Plan.

A visit summary is produced (our letterhead will be added). Edit the text if desired, print, then close the document.

Now move to the Finalize OV tab.

E&M coding is reviewed in another lesson. Here we’ll select Moderate complexity and click Calculate Code.

If the calculated code is acceptable to you, click Submit Code(s).

Residents will need to click Submit to supervising physician for review.

Select your attending, then click Add User(s).

Then click OK.

A resident also needs to view encounter properties to set the Supervising Physician for billing purposes.Right-click on the encounter folder and select Properties.

The resident doctor clicks the Supervisor dropdown arrow, and selects the attending.In this example, we’ll use Dr. Duffy.

Click OK to close the popup.

Now generate today’s visit note.One way to do this would be to click Chart Note.

Your visit note displays.However, this will generate the note in real time, which can tie up your computer for several seconds, or even minutes.

So you’ll probably want to generate the note offline. To do this, hover the mouse over Navigation.

When the Navigation Bar displays, click Offline.

The provider’s work is complete, and the patient can be sent to checkout, or further work can be completed by the staff as necessary.

The Checkout tab may be utilized by office staff to document completion of various orders, referrals, appointments, etc. The degree and manner of its use will be individualized to the workflow of each clinic.

This concludes the NextGenSick Child Visit demonstration.

Why does a round pizza come in a square box?

This concludes the NextGenSick Child Visit demonstration.

Why does a round pizza come in a square box?