Document the Patient's Presenting Concerns

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 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 s

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 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 Clinical Details Using the Short Integrated Note 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. Select Short Integrated 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. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Vital Signs panel, select Add to capture the patient's vitals. In the New Issues panel, document the patient's new issues and the status. In the Risk Assessment panel, document the patient's risks towards suicide or danger to self or properties. Document whether the patient takes medication as prescribed. Document the patient's alleries and their current status. Enter your plan and discussion on the patient's treatment. Note: You can select Copy Forward to copy existing details from another

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Comprehensive Clinical and Nursing 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 Nursing 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. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Vital Signs panel, select Add to capture the patient's vitals. In the New Issues panel, document the patient's new issues and the status. In the Risk Assessment panel, document the patient's risks towards suicide or danger to self or properties. Document whether the patient takes medication as prescribed. Document the patient's alleries and their current status. Enter your plan and discussion on the patient's treatment. Note: You can select Copy Forward to copy existing details from another encounte