Document the Patient's Clinical Event Details

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 a Child and Family Team Meeting 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 CFT Meeting 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. To indicate that the patient did not attend the meeting, select No Show. Enter the meeting details such as location, attendees, and discussions. In the Next Meeting Date field, select the date from the calendar. Document the patient's assessment and diagnosis details. Document the applicable signatures from the tasking supervisor or staff. In the Time Entry Navigation sidebar, select Billing Time En

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Transfer Summary

You can document the patient's transfer details from one program to another. 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 Transfer Summary (BH), and then select OK. Select the program, specialty, and visit type. Select the patient's discharge date. To close the selected program for the patient, select the status of the patient's treatment in the program. In the Assessment/Diagnosis panel, document the patient's active diagnosis and assessment details. In the Transfer Summary panel, document the treatment details, post-transfer support details, risk details, and the reason for the patient's transfer. In the Transfer Plan panel, document the patient's active medications and transfer plans and instructions. Select Generate Document. Assessment and Diagnosis Functionality Parent topic: Transfer Summary

NextGen Behavioral Health Suite Help 5.5

Document the Initial Screening 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 Screening 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. Enter your plan and discussion on the patient's treatment. Note: You can select Copy Forward to copy existing details from another encounter to the current encounter. Document the patient's assessment and diagnosis details. Document the applicable signatures from the tasking supervisor or staff. In

NextGen Behavioral Health Suite Help 5.5

Document Details for the Release of Information to the Patient

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 Release Info panel, document the authorization details, reason for the disclosure, and the contacts involved in the release. In the Documents panel, document the details of the nature of information to be released. Document whether the patient received any privacy notice. Select Generate Document. Parent topic: Individual Visit Workflows for Behavioral Health

Document the Patient's Clinical Event Details

Recommendations

Document a Physician Order

Document the PCP Communication Details

Document a Child and Family Team Meeting Note

Document the Patient's Transfer Summary

Document the Initial Screening Details

Document Details for the Release of Information to the Patient