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Document Integrated Service Plan Information
Document Integrated Service Plan Information
In
NextGen® Enterprise EHR
, in
Patient History
, select the
Templates
button.
The
Select Template
window opens.
On the
Medical Records
tab, select
All
.
From the list, select
Integrated Service Plan (BH)
, and then select
OK
.
Select the program, specialty, and visit type for the patient.
Select whether the treatment program is the initial assessment or an annual update to an existing assessment.
Expand the
Family Vision/Treatment Involvement
panel, and enter details about the patient's treatment program.
In the
Support Resources
section, select
Add
to enter the patient's guardian details.
In the
Person's Strengths
section, select the patient's strengths, and then select
Add
.
Enter details in the
Additional Services/Discharge Plan
panel.
Add the screening tools and the corresponding assessment scores to the current encounter.
Note:
You can open the
Screening Tools
template to complete more assessments by selecting the
Screening Tools
link.
Select the expected discharge date for the patient and the next review date for assessment follow-up.
Select whether the patient agrees with the types and levels of the services included in the
Integrated Service Plan (BH)
document.
Select
Generate Document
.
Add Patient's Need, Goal, Objective, and Intervention Information
You can manage the needs, goals, objectives, and interventions details of a patient.
Assessment and Diagnosis Functionality
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.
NextGen Behavioral Health Suite Help 5.5
Document Patient's Mental Health Details Using the Brief Assessment Template
Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Brief Assessment (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether you have discussed confidentiality and obtained patient's consent for the care. To document the patient's past medical history, select the History Summary link. In the Presenting Concerns panel, do one of the following actions in the Written HPI narrative field: Enter the patient's symptoms and presenting issues that prompted a visit to the office. Use the My Phrases link to select the details for the visit. In the Substance Use/Addictive Behavior panel, select the patient's addiction details to substances. Select the patient's current experiences on physical and domestic violence and other trauma details in the Trauma History panel. Enter the patient's mental status evaluation findings. Comp
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Intake Notes Using the Comprehensive Assessment Templates
Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Comp Assess - Concerns, and then select OK. Select the program, specialty, and visit type for the patient. Complete the assessment in the Concerns tab. Complete the assessment in the Social Hx tab. Complete the assessment in the BH Hx tab. Complete the assessment in the Asses/Plan tab. Select Generate Document. Document the Patient's Presenting Concerns You can document a patient's initial or annual assessment details and the presenting concerns. Document the Patient's Social Support Information You can document the patient's living situation, development history, and other social support details. Document the Patient's Mental Health and Risk Assessment Information You can document the patient's mental health history, substance use, and risk assessment using various screening tools. Document the Summary of the
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Psychiatric Rehabilitation Progress
You can document psychiatric rehabilitation services, and track and review the progress of the patient's treatment plan. 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 Rehabilitation Progress (BH), and then select OK. Note: You can open the Psychiatric Rehabilitation Progress (BH) template from your Packet Navigation, or from the Templates module. For more information on configuring Packet Navigation, go to NextGen Healthcare Success Community, and download the Configuration Guide for NextGen® Behavioral Health Suite. 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 Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select t
NextGen Behavioral Health Suite Help 5.5
Document Group Visit Information
You can document the details of group sessions, including the therapy progress of each individual. There are several types of psychotherapy visits, of these, group visits are a common occurrence in the behavioral health setting. Family and group psychotherapy visits can only be completed for a patient who is already designated as a member of a group in the system. Open NextGen® Enterprise EHR, and then select File > New > Group Encounter. Choose a patient group, and then select OK. To access the Group Prog Note (BH) template, select Select Template Template Icon The Select Template window opens. On the Group tab, select All. Select Group Prog Note (BH). Note: Your practice can also configure the template to be accessible from thePacket Navigation (BH)template. For more information, go toNextGen Healthcare Success Community, and download theConfiguration Guide forNextGen® Behavioral Health Suite. Select the program, specialty, and visit type. Note: Only programs that the patient is acti
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
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Case Management Services in the Contact Note
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 Contact Note (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 Goals, Objectives, and Interventions Addressed Today panel, document the patient's goals, objectives, and interventions addressed on the current date. Enter your plan and discussion regarding the patient's treatment. Note: You can select Copy Forward to copy existing details from another encou
