Assessment and Diagnosis Functionality

Assessment/Diagnosis Panel Functions Available	Related Topics
Add a Diagnosis	Add an Admitting Diagnosis Add an Existing Client Diagnosis Add a Diagnosis Using Diagnosis Code Lookup Add a Diagnosis Using Common Assessment Add Diagnosis Details
Sort Assessment Order	Sort Assessment Order
View or Document Psychosocial Stressors and GAF Score	Document Psychosocial Stressors and GAF Score
View or Complete a WHODAS Screening	Document WHODAS Response
Document Active Diagnosis	Select the Note icon next to the Active Diagnosis link to generate a document with the list of active diagnoses in the Active Assessments (BH) template.
Complete the custom questionnaires	Select Configurable Questionnaires to document the pre-configured questions on the Additional Visit Information template and include its details in the generated document. Your Practice administrators can configure the questionnaires on the Additional Visit Information Config practice template. Practice administrators can select a Specialty and create a Category for the new questionnaires, and then create new questions in the Additional Visit Information section.
Diagnosis Code Lookup	Select Diagnosis Code Lookup to search and select the ICD code and add it to the Active Diagnosis grid.

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 Diagnostic Details

In the Assessment/Diagnosis panel, confirm the assessment selected displays in the Description details and ICD Code field. If not, select the assessment in the grid to fill in the details. 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. If applicable, select Present on Admission and then select a description from the list. To indicate the diagnosis is chronic, add the diagnosis to the client’s clinical problems list, and/or add the assessment to my tracked problems, select the respective checkbox. Select Add To Grid. The information displays in the grid. To add psychosocial stressors, select the Psychosocial Stressors link. To add referrals, select the Referrals link. To reorder the diagnoses, select Sort. To update a diagnosis, select the diagnosis in the grid, modify the details, and select Update. Parent t

NextGen Behavioral Health Suite Help 5.5

Task Supervisor/Staff for Review and Signoff

The table provides information about the tasks related to the Signature (Tasking Supervisor/Staff for review and signoff) panel. You can request secondary approval or attestation from another user, through the Signature (Tasking Supervisor/Staff for review and signoff) panel. To generate the document, select Generate Document. Tasks Related Topic Request Secondary Approval Request Secondary Approval Provide Secondary Approval Provide Secondary Approval Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates Parent topic: Document Patient's Mental Health Details Using the Brief Assessment Template Parent topic: Document Integrated Service Plan Information Parent topic: Document Patient's Trauma History using the LEC-5 Interview Template Parent topic: Document Nutritional Assessment Information Parent topic: Document Serious or Traumatic Life Events Parent topic: Managing Patient's Addiction Details Parent topic: Document the Patient's Psychiatric R

NextGen Behavioral Health Suite Help 5.5

Submit Charges

Before you begin Service codes, units, and duration are configured on the Service Code Mapping panel in the BH Foundation Configuration template. If any of these fields are blank, the selected code may not be configured correctly. Your practice administrator must review the configuration. For more information, go to NextGen Healthcare Success Community and download the Configuration Guide for NextGen® Behavioral Health Suite. Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Open the billing template, and expand the Charges panel. If the service is not billable, select No Billing for Service, and then skip the remaining steps. Enter the start and end times. Note: If the end time is earlier than the start time, or the duration is more than 12 hours, a message appears to correct the entries. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the end time.

NextGen Behavioral Health Suite Help 5.5

Document WHODAS Response

The WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) link can be found in the Assessment/Diagnosis panel of all billable BH templates or from the Screening Tools template located from the template header link. From the BH - WHODAS template, complete questions S1 – S12. Note: Raw score or Score percentage does not display unless all questions are completed. For questions H1-H3, use the number pad to enter the number of days. The Raw score and Score percentage calculates and displays in the corresponding fields. Select Save & Close. The Raw score and Score percentage display on the Assessment/Diagnosis panel of the encounter. A record of the screening also displays in the Screening Tool grid on the Screening Tool window. Parent topic: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) Related concepts WHO Disability Assessment Schedule 2.0 (WHODAS 2.0)

NextGen Behavioral Health Suite Help 5.5

Sort Assessment Order

For billing or documentation purposes, it may be necessary to modify the order in which the assessments are displayed on your documentation. From the Assessment/Diagnosis panel, select Sort. The Reorder Assessments window opens. Reorder Assessments window From the Existing Sort Order grid, select the assessment to display first in the list. The assessment displays as #1 in the New Sort Order grid. From the Existing Sort Order grid, select the assessment to display next in the list. The assessment displays as #2 in the New Sort Order grid. Repeat step 3 until all assessments on the encounter display correctly in the list. Reorder Assessments window To move the remaining assessments without changing the order to the New Sort Order grid, select Move Remaining. To remove an assessment added to the New Sort Order grid in error, use either Undo Last or Undo All. Select Save & Close. Parent topic: Behavioral Health Assessment and Diagnosis

Assessment and Diagnosis Functionality

Recommendations

Add a Diagnosis Using Diagnosis Code Lookup

Add Diagnostic Details

Task Supervisor/Staff for Review and Signoff

Submit Charges

Document WHODAS Response

Sort Assessment Order

Assessment and Diagnosis Functionality

Add a Diagnosis Using Diagnosis Code Lookup

Add Diagnostic Details

Task Supervisor/Staff for Review and Signoff

Submit Charges

Document WHODAS Response

Sort Assessment Order