Add Diagnostic Details

NextGen Behavioral Health Suite Help 5.5

Add an Existing Diagnosis to the Current Encounter

Open NextGen® Enterprise EHR. For a patient encounter, open an assessment template. From the Assessment/Diagnosis panel, select a diagnosis in the Active Diagnosis grid. The Diagnostic description and ICD Code field fills in. Alternatively, in the Last Encounter Diagnosis for Current Provider section, select Copy Forward. Note: When all the diagnoses from the last encounter for the current provider are active, the data is forwarded to the Diagnosis grid. If one or more such diagnosis is not active, the Copy Forward button is not available. You can select the diagnoses manually to add them to the Diagnosis grid. Add Status, Severity, Differential Dx, and Impression. To enter specifiers in the Specifiers field, do one of the following: Select in the field and enter free text. Select the My Phrases link and select a phrase from the list. In the Present on Admission field, select a description from the list. The Description field fills in based on the selection made. Select admitting diagn

NextGen Behavioral Health Suite Help 5.5

Add a Diagnosis Using Diagnosis Code Lookup

From the Assessment/Diagnosis panel, open the Diagnosis Search window by doing one of the following: Select into the Diagnostic description field. Select the Diagnosis Code Lookup link. In Enter Search Item, you can type a key work or diagnosis code to begin the search. To filter the search results, you can use one of the following filters: To view new diagnoses from the ICD-10 library, select All Diagnoses in the left-hand panel. To view the client’s diagnoses or chronic diagnoses, select the respective option in the left-hand panel. To view diagnoses added to your favorites list, select Favorites from the left-hand panel. To search by specific categories, select Categories in the left-hand panel. Search results matching the keyword or diagnosis code entered displays in the right-hand panel. Select the assessment and then select Select. The Diagnosis Search window closes. The Diagnostic description and ICD Code fields display the selected diagnosis information. Enter the diagnostic de

NextGen Behavioral Health Suite Help 5.5

Add a Diagnosis Using Common Assessment

From the Assessment/Diagnosis panel, select the Add Common Assessment link. The Common assessment window opens. Select a diagnosis. If the diagnosis you selected has a + in front of it, more than one code exists. You need to select the link and select from a secondary list. The BH – Severity window opens. Select the severity from the list and then select Close. To add additional diagnoses, repeat steps 2 and 3. Select Save & Close to save your assessment and return to the previous screen. The assessments display in the grid on the Assessment/Diagnosis panel. Enter the diagnostic details. Parent topic: Behavioral Health Assessment and Diagnosis

NextGen® Adaptive Content Engine Help Enterprise 8

Complete the Diagnoses Section for Transfer/Discharge

In the Behavioral Health Diagnoses section, select any of the available links: Diagnosis Code Lookup Add Common Assessment Mandated Care Coordination In the required Diagnostic description field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. In the Status field, click to select a value from the list. If appropriate, enter a Severity. If needed, enter a Differential dx, and/or Impression. To enter Specifiers, click one of the following: In the field to manually enter any required values The My Phrases link. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. For chronic conditions, select the option to Mark diagnosis as chronic. Select the options to add the assessment to the Clinical problems, My tracked problems, and/or My favorites where applicable. Click Add To Grid. In the Physical Hea

NextGen® Adaptive Content Engine Help Enterprise 8

Document an Assessment

To add or edit a diagnosis on the Add or Update Assessment template, use one of the following sections: Billing Diagnosis History Clinical Problems My Favorites The new or revised diagnosis appears in the list of diagnoses in the Today's Assessment grid. If a working assessment does not exist, the diagnosis information appears in the ICD description and ICD Code fields. If your practice required a status when you selected the diagnosis, it appears in the Status field. If a working assessment exists, it remains selected in the Today's Assessment grid, and the ICD description, ICD code, and status for the working assessment are retained. To change the working assessment, select the diagnosis being addressed for this encounter in the Today's Assessment grid. The selected diagnosis becomes the new working assessment that carries forward to the other templates that share the assessment. To change the ICD code, click the ICD Code field and search for and select the correct code for the diagn

NextGen® Adaptive Content Engine Help Enterprise 8

Update the Assessment Details in Today's Assessments grid

If you want to update the assessment details in the Today's Assessments grid, Highlight an assessment in the Today's Assessments grid. Select or enter appropriate value in the Status, Side, Site, Impression, Differential Dx fields. Click Update. If the diagnosis is chronic, select the Mark diagnosis as chronic check box. If you want to add the selected assessment to the problem list, tracked problems, and/or favorite list, select the Clinical problems, My tracked problems, and/or My favorites check box respectively. Note: You can click the other tabs such as My Plan, A/P Details, and so on to document treatment plan, prescribe medications, order labs or X- rays, and request referrals. Parent topic: Upload the Procedure Diagnosis in Today's Assessment Grid

Add Diagnostic Details

Recommendations

Add an Existing Diagnosis to the Current Encounter

Add a Diagnosis Using Diagnosis Code Lookup

Add a Diagnosis Using Common Assessment

Complete the Diagnoses Section for Transfer/Discharge

Document an Assessment

Update the Assessment Details in Today's Assessments grid

Add an Existing Diagnosis to the Current Encounter

Add a Diagnosis Using Diagnosis Code Lookup

Add a Diagnosis Using Common Assessment

Complete the Diagnoses Section for Transfer/Discharge

Document an Assessment

Update the Assessment Details in Today's Assessments grid