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NextGen Behavioral Health Suite Help 5.5
Document Patient's Mental Health Details Using the Brief Assessment Template
Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Brief Assessment (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether you have discussed confidentiality and obtained patient's consent for the care. To document the patient's past medical history, select the History Summary link. 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. In the Substance Use/Addictive Behavior panel, select the patient's addiction details to substances. Select the patient's current experiences on physical and domestic violence and other trauma details in the Trauma History panel. Enter the patient's mental status evaluation findings. Comp
NextGen Behavioral Health Suite Help 5.5
Managing Patient's Addiction Details
Your practice can configure the Addiction Severity Index (BH) to be accessible from your Packet Navigation or you can access the template from the Templates module . For more information, go to NextGen Healthcare Success Community and download the Configuration Guide for NextGen® Behavioral Health Suite. On the General Information and Severity Profile panels, you can select the information icon for tips on using the specific panels during the interview. After documenting the potential problem areas for the client, you can submit charges for the encounter or select the No Billing for Service checkbox. By selecting Addiction Severity Index, you can generate the Addiction Severity Index document, which displays the documented data for the patient. Select Program, Specialty, and Visit Type You can document the patient's billing and case management details. Document General Addiction Severity Index Information Severity Profile Assessment and Diagnosis Functionality Task Supervisor/Staff for
NextGen Behavioral Health Suite Help 5.5
Document Patient's Trauma History using the LEC-5 Interview Template
In NextGen® Enterprise EHR, in Patient History, select the Templates button. The Select Template window opens. On the Medical Records tab, select All. From the list, select LEC-5 Interview (BH), and then select OK. Select the program, specialty, and visit type for the patient. In the Rate Emotional Abuse Severity panel, enter the rating after completing all the questions on the patient's emotional status. In the Rate Physical Abuse Severity panel, enter the rating after completing all the questions on the patient's physical status. In the Rate Sexual Assault or Other Uncomfortable Sexual Experience Severity panel, enter the rating after completing all the questions on the patient's sexual assault experiences. In the Rate Other Stressful Event Severity panel, document the patient's exposure to other stressful events such as war, life-threatening illness, sudden violent death, or serious injury you have caused to someone else. In the Event Rating and Summation panel, document the overall
NextGen Behavioral Health Suite Help 5.5
Nursing and MA Documentation
The NextGen® Behavioral Health Suite provides a variety of long and short notes designed for documenting nursing services. The table below provides details on intended use for each template. Template Designated Use Short Integrated Note (BH) Medical assistant or similar supporting staff to document clinical information Nursing Note (BH) Nursing staff to document nursing services Integrated Note (BH) Medical assistant or similar supporting staff to document nursing services, including updates or changes to a client's review of systems or physical exam Integrated Nursing Note (BH) Nursing staff to document nursing services, including updates or changes to a client's review of systems or physical exam Document the Patient's Clinical Details Using the Short Integrated Note Template You can document the patient's clinical details such as medication information, risk assessment details, and allergies. Document the Patient's Nursing Services You can document the patient's nursing services and
NextGen Behavioral Health Suite Help 5.5
Document Integrated Service Plan Information
In NextGen® Enterprise EHR, in Patient History, select the Templates button. The Select Template window opens. On the Medical Records tab, select All. From the list, select Integrated Service Plan (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether the treatment program is the initial assessment or an annual update to an existing assessment. Expand the Family Vision/Treatment Involvement panel, and enter details about the patient's treatment program. In the Support Resources section, select Add to enter the patient's guardian details. In the Person's Strengths section, select the patient's strengths, and then select Add. Enter details in the Additional Services/Discharge Plan panel. Add the screening tools and the corresponding assessment scores to the current encounter. Note: You can open the Screening Tools template to complete more assessments by selecting the Screening Tools link. Select the expected discharge date for the patient
NextGen Behavioral Health Suite Help 5.5
Individual Visit Workflows for Behavioral Health
Individual visit workflows for NextGen® Behavioral Health Suite are found in the following section. Document the Assessment and Billing Information You can document the billing details for an assessment service even without completing a full comprehensive assessment. Document the Adult Recovery Team Meeting Note You can document the details of the meeting conducted by the adult recovery team. Document a Child and Family Team Meeting Note You can document the patient's details from the child and family team meeting. Document the Patient's Case Management Services in the Contact Note You can document the patient's billing and case management details. Document Care Coordination You can document the caregivers' coordination towards the patient's care. Document Client Requests for Services You can document client request for services and meet the routine care needs and initial evaluation measures. Document a Physician Order You can document the orders requested by the patient's physicians.
Document the Patient's Intake Notes Using the Comprehensive Assessment Templates
Open
NextGen® Enterprise EHR
, and then in
Patient History
, select
Open Templates
.
The
Select Template
window opens.
On the
Medical Records
tab, select
All
.
From the list, select
Comp Assess - Concerns
, and then select
OK
.
Select the program, specialty, and visit type for the patient.
Complete the assessment in the
Concerns
tab.
Complete the assessment in the
Social Hx
tab.
Complete the assessment in the
BH Hx
tab.
Complete the assessment in the
Asses/Plan
tab.
Select
Generate Document
.
Document the Patient's Presenting Concerns
You can document a patient's initial or annual assessment details and the presenting concerns.
Document the Patient's Social Support Information
You can document the patient's living situation, development history, and other social support details.
Document the Patient's Mental Health and Risk Assessment Information
You can document the patient's mental health history, substance use, and risk assessment using various screening tools.
Document the Summary of the Patient's Assessments
You can document your plans for medications and diagnoses based on the patient's assessments.
Task Supervisor/Staff for Review and Signoff
The table provides information about the tasks related to the
Signature (Tasking Supervisor/Staff for review and signoff)
panel.
Submit Charges
You can use the Charges panel to submit a charge for the billing process.
