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Document the Patient's Mental Health and Risk Assessment Information
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 - BH Hx
, and then select
OK
.
To document the patient's medical and surgical details in the
Past Medical/Surgical
panel, select
Add
.
Note:
To document the patient's mental and physical health details, you can select the corresponding links in the
Past Medical/Surgical
panel.
In the
Substance Use/Addictive Behavior History
panel, document the details about the patient's addiction to substance use.
In the
Mental Health and Addiction Treatment Service
panel, document the patient's treatment details about the mental health and substance use.
In the
Medication Information
panel, review and update the patient's medication details.
In the
Mental Status Evaluation
panel, enter the patient's mental health details.
Note:
To document the patient's mental health status systematically, you can select the
Mental status exam
link in the
Mental Status Evaluation
panel.
In the
Risk Assessment
panel, complete the corresponding risk assessment templates.
In the
Past Risk and Alerts
panel, document the patient's history of suicidal and self-injury risk.
In the
Screening Tools
panel, complete the corresponding screening questionnaires for the patient's mental health and substance addiction.
Document the Patient's Medical and Surgical Details
You can document the patient's mental health history, substance use, and risk assessment using various screening tools.
Document the Patient's Mental Health and Risk Assessment Information
NextGen Behavioral Health Suite Help 5.5
Document the Summary of the Patient's Assessments
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 - Assess/Plan, and then select OK. In the Life Goals, Strengths, Abilities and Barriers panel, enter the details of the patient's life goals, strengths, abilities, and barriers. In the Barriers to Care panel, document the obstacles to the patient's care. In the Service panel, enter the patient's care preferences and environmental support details. In the Clinical Formulation/Interpretative panel, document the patient's clinical summary. In the Treatment Recommendations/Assessed Needs panel, document recommendations for the patient's treatment and follow-up evaluations. Select Generate Document. Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Social Support Information
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 - Social Hx, and then select OK. In the Living Situation panel, document the patient's current living details such as address, residential treatment, household composition, and risk assessment. In the Family Information panel, document the details about the patient's family members, family history of mental illness or substance addiction, and the emotions attached to the family members. In the Development panel, document the patient's motor and sensory development history. In the Abuse/Sexual Risk Behavior panel, document the details about any physical, sexual, or emotional abuse, the patient has experienced. In the Social Support panel, document the details about the support the patient receives from relationships, religion, and community. In the Legal panel, document the details about the patient'
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Presenting Concerns
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. Document whether the assessment is the initial assessment or an annual update to an existing assessment. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Presenting Concerns panel, enter the details of the patient's current concerns and the required help. Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates
NextGen Behavioral Health Suite Help 5.5
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
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Medical and Surgical 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. From the list, select Comp Assess - BH Hx, and then select OK. In the Past Medical/Surgical panel, select Add to document the patient's medical and surgical details. To add an item to the Medical or Surgical panel, select the respective checkbox for the condition or surgery. The Onset Date (in the Medical panel) or Date (in the Surgical panel) field and the DetailsDetails Icon icon appear beside the selected item. To add problems that are not available on the Past Medical History template, use the Other field. Use the Onset Date field in the Medical panel to enter the date when the condition first appeared. Use the Date field in Surgical panel to enter the date the surgery was performed. Select Onset Date or Date to access the Date Selection window. The Data Selection window opens. You can enter the Onset date manually into Onset da
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
