Document Details for the Release of Information to the Patient

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Psychiatric Directive

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Psychiatric Advance Directive (BH), and then select OK. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the General panel, document the directives for the billing guidelines. In the Psychiatric Healthcare Proxy panel, document the details of the healthcare proxy. In the Directives on File panel, document the pre-configured evaluation questions. In the Medication Choices panel, document the medications agreed upon and refused by the patient. In the Hospital/Provider Choices panel, document the hospital and provider details. Document the review status of the directive. Select Generate Document. Parent topic: Individual Visit Workflows for Behavio

NextGen Behavioral Health Suite Help 5.5

Document a Physician Order

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Physician Orders (BH), and then select OK. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Physician Orders panel, document the order details from the patient's physician. Document the applicable signatures from the tasking supervisor or staff. In the Labs panel, document the orders related to the patient's lab, radiology, and immunization. Select Generate Document. Parent topic: Individual Visit Workflows for Behavioral Health

NextGen Behavioral Health Suite Help 5.5

Document the PCP Communication Details

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select PCP Communication (BH), and then select OK. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Reason for Communication panel, document the reasons for the patient's communication with the PCP. In the Vital Signs panel, document the patient's vital signs such as height, weight, body temperature, blood pressure, respiration, and pain level. In the Allergies panel, review and update the patient's allergy details. In the Medications panel, review, update, and reconcile the patient's medications. In the Orders panel, document the follow-up orders on the patient's lab, radiology, immunization, and task orders. Document the patient's assessment and

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Suicide Risk Assessment

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Eval of Suicide Risk (BH), and then select OK. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. Document the reason for the suicide risk assessment. Document the patient's historical, clinical, and situational risk factors. Document the protective factors for the patient's mental health. Document the recommendations based on the patient's current assessment. Select Save. Parent topic: Individual Visit Workflows for Behavioral Health

NextGen Behavioral Health Suite Help 5.5

Document Care Coordination

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Care Coordination (BH), and then select OK. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Care Coordination Team panel, document agency and interdisciplinary team details. In the Barriers to Care panel, document the potential barriers to care, and then record work done to resolve those barriers. In the Care Plan History panel, document the care plans for the patient such as needs, goals, outcomes, interventions and progress details. In the Care Coordination panel, document the ca

NextGen Behavioral Health Suite Help 5.5

Document the Assessment and Billing Information

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Assessment/Reassessment Billing (BH), and then select OK. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Treatment Recommendations/Assessed Needs panel, document the recommended treatments and the patient's needs. Document the patient's assessment and diagnosis details. Document the applicable signatures from the tasking supervisor or staff. In the Time Entry Navigation sidebar