NextGen Knowledge Center

Document Patient's Mental Health Details Using the Brief Assessment Template

  1. Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates.
    The Select Template window opens.
  2. On the Medical Records tab, select All.
  3. From the list, select Brief Assessment (BH), and then select OK.
  4. Select the program, specialty, and visit type for the patient.
  5. Select whether you have discussed confidentiality and obtained patient's consent for the care.
  6. To document the patient's past medical history, select the History Summary link.
  7. 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.
  8. In the Substance Use/Addictive Behavior panel, select the patient's addiction details to substances.
  9. Select the patient's current experiences on physical and domestic violence and other trauma details in the Trauma History panel.
  10. Enter the patient's mental status evaluation findings.
  11. Complete an exam on the patient's behavior and mental condition by selecting the Mental Status Exam link in the Mental Status Evaluation panel.
  12. Complete the risk assessment templates in the Risk Assessment panel.