OSIS Insights

Dental

NextGen® Electronic Dental Record – Documentation Basics

Posted by Nicole Miller on Dec 29, 2020 11:29:05 AM

The NextGen Electronic Dental Record (EDR) is an asset for Community Health Centers that provides improved collaboration and maximizes patient data within your practice. Virtually everyone in your organization uses your electronic system(s) to capture, share, and leverage data—from clinical information, to protected health information (PHI), to financial/claims data. 



In this post, OSIS guides you through the basics to documenting in NextGen EDR.  

Documenting starts with the basic Patient Chart View, with each section containing additional detail and navigation for the end-user.  In this initial screen, you will find patient’s information including documentation completed in the past, existing dental plans, upcoming plans, or plans from today’s visit.    

Below the tooth chart, procedures and notes will be provided for the patient including the History and Planned documentation.   

  • History shows the procedures provided by your practice or by another provider.  
  • Planned will show future treatment plans.  
  • Both will show both History and Planned for easy viewing.
Patient Chart

Icon Tool Bar 

The Icon Tool Bar gives access to different areas in the patient chart and is customizable per practice needs or individual needs.  What is great about the toolbar is that there can be a default Tool Bar, a Provider Tool Bar, or even a Hygiene Tool Bar. To learn about additional toolbar icons available, we have listed out the icons and their functionality below. Not all icons are shown on the tool bars, so each end-user can customize the icons to what works best for their daily documentation.  

Tool Bar

Tool Bar Examples

  • File Menu – Provides access to various areas in EDR and is very important to understand what the icon is used for.  Some of the applications are only accessible through this icon 
  • Application Log Off – This allows staff to log off the application and allow other staff to log in and should always be used 
  • Patient Search – This is used to locate a patient’s chart by using demographic information such as last name or date of birth  
  • Appointment Search  Easy access to the patient’s dental appointments by location, provider, or patient 
  • Tooth Chart – Allows for patient chart view with history or planned treatments 
  • Patient Summary – Provides access to the patient summary details post visits 
  • X-Ray Software – This function directs user to the x-ray software imaging  
  • Document Files – Used when scanning documents into the EDR. These documents do not appear in the EHor DM Application 
  • Perio Exam – This is used to perform a new exam, edit an existing exam, or compare exams 
  • Group Treatments – Set planned treatments in specific grouping types. Ex: are next visit or pending authorization 
  • Complete Treatments – Action when planned treatments are to be completed in today’s visit 
  • PM Application – Toggle to the Practice Management application where appointments and Patient Primary Demographic Chart can be accessed 
  • EHR Application – Toggle to the Electronic Health Record to access the medical chart for access to the Medication Orders, Alerts, and Problem modules 

Patient Information Bar

Under the Icon Bar is the Patient Information Bar. To ensure that documentation is being completed on the correct patient, patient details should always be confirmed from the Patient Information Bar with the Four Point Check. The four pieces of information below need to be confirmed on each patient.  

  • Patient Name 
  • Date of Birth  
  • Encounter Number  
  • Provider 

Patient Information Bar

OSIS recommends using the additional details available by clicking on the arrows in the Patient Information Bar. These extra features display the patient demographics, encounter details, and user information to help provide an integrated system to share information intelligently between dentists and physicians.  The additional details in the EDR improves data capture, easier data sharing, and improves access with NextGen EHR and EPM. 

The Patient Information details will give you the bulk of the demographic patient information and may reduce the amount of time spent toggling back to the EPM. This is also a good place to check the age of the patient if you are doing a Carries Risk Assessment (CRA) on the patient.  If you are wondering about workflow and setup of the CDA, visit our post to learn more. 

The Encounter Information is important because it shows the Payer.  This offers the opportunity to check if the patient has a dental payer attached and not a medical payer here instead of linking to the EPM. 

The User Information identifies the user, database, and the workstation in use. 

Patient Chart Icons  

The patient chart is comprised of all the icons pictured hereSome icons will also change the view of the patient chart for ease of reading or documentation.  

NextGen EDR Patient Chart Icons

Listed below are three icons that OSIS finds really important and will be really useful in NextGen EDR 5.8. UD3.

Manage Treatment Plan – If you set treatment plan groups and organize treatments, this is important to have set up in your practice.  

Check Service Restrictions – Ithe payer is setup, there are certain restrictions that will show for the procedure in the future treatment plan or treatment in that visit. This is a time saver. 

Show Reauthorizations – Additional set up is required and this feature is highly recommended to reduce the amount of time moving back and forth from the EDR to the EPM.  

Tooth Chart 

The Tooth Chart is a graphical view of the patient’s dental chart. This will show historical dental work, planned dental work, and current visit dental work completed. Based off the tooth chart below, we can identify what procedures for each tooth were documented on the patient. NextGen EDR Tooth Chart

Palette 

The Palette is where the services and conditions can be documentedA list of service codes to choose from will display after you select a service button.  For example, choosing the Exam Service, the list of codes pertaining to the exam will populate to choose from. The palette is customizable and can be leveraged with Smart Notes in addition to the EHR.   

Smart Notes are a critical way of communicating information about a patient's dental and sometimes medical healthcare using interactive and predefined notes.  We encourage practices to use Smart Notes to create consistent and comprehensive notes by removing the need to recreate the same type of documentation over and over. To read more about Smart Notes, visit our blog post 

Palette

Details  

The Details in the chart display historical dental records as well as planned treatments. The historical details include items such as services performed, provider notes, x-ray images, and documents scanned.  

The planned treatment details will have the services that are to be performed in future visits. The services may show in groups based on treatment.

The best is yet to come!  

The implementation of the new EDR 5.8. UD3 coming soon will have the following enhancements 

  • The Patient Information Bar will be available for EDR 
  • Treatment Plan Groups can be linked to an appointment  
  • Copy a Treatment Plan to Enterprise EHwill be available  
  • The option to Add a Referral to EHR from EDR will be a game changer 

For more information on implementing NextGen EDR into your practice, please email info@osisonline.net. 

Resources: NextGen, Top Six Reasons an Integrated EDR Improves Your Health Center 

Topics: Community Health Center, FQHC, NextGen EDR