Document the Patient's Progress in the Opiate Treatment Program
- 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 Opiate Treat Progress 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.
- Select the opiate treatment program.
- In the Individuals Present panel, document the details of the individuals present during the assessment.
Note: The Homework data from the last session is displayed from the most recent encounter by the same provider on the Opiate Treat Progress Note (BH), IDD Summary Progress Note (BH), and Progress Note (BH) templates. The Copy Forward option copies the last session homework data to the Homework Assigned field in the Plan panel.
- In the Current Assessment panel, document the patient's progress and notes regarding changes to their mood changes, thought process, motor activity and speech, behavior, medical condition, and substance use.
- In the Barriers to Care panel, document the potential barriers to care, and then record work done to resolve those barriers.
- In the Goals, Objectives, and Interventions Addressed Today panel, document the patient's goals, objectives, and interventions addressed on the current date.
- Enter your plan and discussion regarding 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.
- In the New Issues panel, document any new issues faced by the patient.
- In the Urine Drug Screen panel, document the drug details for the patient's urine assessment.
- In the Treatment Phase Progress panel, document the progress of the patient's treatment phases.
- In the Treatment Phase History panel, document the treatment phases for the patient.
- Document the applicable signatures from the tasking supervisor or staff.
- In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the end time.
Note: You can select the current time or enter the time manually.
- In the Charges panel, document the billing details.
- Optional: Select No Billing for Service if there is no charge for the current date.
- Select Generate Document.
- Document Information about Individuals Present during an Assessment
You can document details about the individuals present during the patient's assessment. - Document Goals, Objectives, and Interventions
You can document the patient's goals, objectives, and interventions. - Assessment and Diagnosis Functionality
- 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.