Document Psychosocial Stressors and GAF Score

NextGen® Adaptive Content Engine Help Enterprise 8

Document Physical Health Diagnoses and Psychosocial Stressors

Navigate to the Assessment/Diagnosis panel. In the Physical Health Diagnoses Affecting Behavioral Health section, click the first available field to open the BH - Reported By Patient picklist and select a value. Click Psychosocial Stressors to enter psychosocial stressors and related details. To document a referral, click the Referrals link. Physical Health Diagnoses Affecting Behavioral Health in the Assessment/Diagnosis Panel Note: The Current GAF and Highest GAF in past year field values carry forward to future encounters. Click the GAF Scale link to review descriptions of how the GAF score is calculated. Click either field, Current GAF or Highest GAF in the past year, to enter a value. The current encounter date automatically fills the corresponding date field. Parent topic: Enter Assessment and Diagnosis Details

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

Enter Assessment and Diagnosis Details

Expand the Assessment/Diagnosis panel. If enabled, click the DSM IV link in the upper, right corner to launch the BH – DSM IV template. Note: The display of the link is set up on the Behavioral Health section of the Practice Configuration system template. In the Behavioral Health Diagnoses section, select any of the available links. In the Diagnostic description required field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. Add Status, Severity, Differential DX, and Impression. The out-of-the-box Severity picklist does not include Extreme or Persistent. These values can be added to the list in File Maintenance. Enter any required Specifiers by doing one of the following actions: Click the field to type a value. Click the My Phrases link to create a new sentence or part of a sentence. For more information about My Phrases, go to NextGen Healthcare Success Community and download the latest Getting Start

NextGen Behavioral Health Suite Help 5.5

Document Psychiatric Screening Details in the BPRS Template

You can quickly gather information about the possible presence and severity of various psychiatric symptoms using the Brief Psychiatric Rating Scale (BPRS) template. Open NextGen® Enterprise EHR. For a patient encounter, open a template. In the header link section, select Screening Tools. The Screening Tools template opens. Select BH Brief Psychiatric Rating Scale (BPRS). The BH Brief Psychiatric Rating Scale (BPRS) template opens. The encounter date is the default date in the Performed Date field. BH Brief Psychiatric Rating Scale (BPRS) Optional: Select an alternate date in the Performed Date field. Rate all the listed problems based on the condition of the patient. In the Interpretation of Results section, select Calculate Score. A two-digit score appears in Total Score. Based on the combined total score, a default interpretation appears in Interpretation. Total Score field Optional: To override the calculated interpretation, select a new Interpretation. Note: You can enter addition

NextGen® Adaptive Content Engine Help Enterprise 8

Add Psychosocial Stressors for the Client

The information gathered on the Bh Psychosocial Stressors template was previously included in the Axis IV section of the Assessment/Plan panel under the DSM IV standards. Information may be pre-populated when you enter the Bh Psychosocial Stressors template as the data carries forward from one encounter to the next unless the New Intake button has been selected at the beginning of the Comprehensive Assessment (Concerns tab, General panel). On the Bh Psychosocial Stressors template, select one of the descriptive status options. BH Psychosocial Stressors In the Problems related to section, select No or Yes and enter additional information in the corresponding field for the following areas: Primary support group Social environment Education Occupation Housing Finances Legal system/crime Accessing healthcare Other To enter additional information, click the Comments field. Click Save & Close. Parent topic: Enter Assessment and Diagnosis Details

NextGen® Adaptive Content Engine Help Enterprise 8

DSM-5 Overview

The Diagnostic and Statistical Manual of Mental Disorders (DSM) manual is the primary source used by clinicians to diagnose and classify mental disorders. The date of implementation for the Fifth Edition (DSM-5) coincided with the go-live date for the International Classification of Diseases and Related Health Problems 10th Revision (ICD-10), which is also required for reporting and claim submissions. DSM-5 is needed to assign Health Insurance Portability and Accountability Act (HIPAA) compliance and valid diagnosis code Clinical Modifications (ICD-10-CM) to a psychiatric diagnosis. The Behavioral Health template set in NextGen® Adaptive Content Engine includes revised functionality to enable the documentation of assessments using the standards in the latest manual. The Assessment/Diagnosis panel, which has always been specific to Behavioral Health, is updated to reflect the DSM-5 standards. The Global Assessment of Functioning (GAF) data is available on the Assessment/Diagnosis panel

Document Psychosocial Stressors and GAF Score

Recommendations

Document Physical Health Diagnoses and Psychosocial Stressors

Complete the Diagnoses Section for Transfer/Discharge

Enter Assessment and Diagnosis Details

Document Psychiatric Screening Details in the BPRS Template

Add Psychosocial Stressors for the Client

DSM-5 Overview

Document Physical Health Diagnoses and Psychosocial Stressors

Complete the Diagnoses Section for Transfer/Discharge

Enter Assessment and Diagnosis Details

Document Psychiatric Screening Details in the BPRS Template

Add Psychosocial Stressors for the Client

DSM-5 Overview