NextGen Knowledge Center

Document the Clinician's Shift Notes

You can document three separate shifts per day using the Shift 1, Shift 2, and Shift 3 tabs within the Residential Administration (BH) template. You can select each tab to open the corresponding templates for documenting each shift. Each section or tab includes the same functionality. The entered goals, objectives, and interventions are specific to each shift and do not carry over from the previous shift template. All documentation entered on the shift note for the patient is consolidated into one note that covers all three shifts. All three shifts should occur within a 24-hour period.

  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. Select Residential Shift Note (BH), and then select OK.
  4. Select the program, specialty, and visit type.
  5. Verify and select whether the patient's name and encounter dates are correct.
  6. Select the Shift 1, Shift 2, or Shift 3 tab to document the corresponding shift.
  7. Select the start and end times of the selected shift.
  8. Document the patient's daily activities to monitor and track the residential services.
  9. In the Goals, Objectives, and Interventions Addressed Today panel, document the patient's goals, objectives, and interventions addressed on the current date.
  10. In the Client Tracking panel, document the patient tracking details.
  11. Document the patient's mood and shift plans for the residential services.
  12. Document permissions and restrictions for the patient and log all the visits and calls that the patient receives.
  13. Document the patient's assessment and diagnosis details.
  14. Document the applicable signatures from the tasking supervisor or staff.
  15. Select the next shift you need to update.
  16. Select Generate Document.