Document the Patient's Initial Psychiatric Evaluation Summary

As a psychiatrist, nurse practitioner (NPP), or other behavioral health professional, you can document an initial psychiatric assessment of the patient.

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 Psych Eval (BH), and then select OK.
   Note: You can open the Psych Eval (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.
4. 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.
5. In the Individuals Present panel, document the details of the individuals who accompanied the patient during the assessment.
6. In the General panel, select whether the patient is an established patient or a new patient.
7. In the Reason for Visit panel, document the reason for the patient's visit.
8. In the Review of Systems panel, review and document the patient's social and developmental history.
   Note: For the subsequent encounters, you can select ROS History to review the copy-forwarded history of records from the previous encounters.
9. Document the patient's vital signs.
10. Document the patient's physical and mental health details.
11. Select whether the patient has experienced any substance use addiction.
12. Document the patient's motor development history.
13. In the Family Information panel, document the patient's family details and family history of mental illness and substance abuse.
14. Document the patient's sexual orientation, practice, and history.
15. Document the patient's medical surgical history and mental status examination details.
16. In the Risk Assessment panel, document the patient's suicidal and homicidal risk assessment details.
17. Document the assessment and active diagnosis details of the patient.
18. In the Medication Information/Consent panel, document the patient's active medications, consent details, and the medication status.
    Note: You can select the record in the Consent grid, and then select the Active medications from the list.
19. Document the patient's social involvement in relationships, education, nutrition, and environment.
20. Document the plans and additional details about the patient's mental health.
21. To finalize the billing process, select EM Coding.