Document the Patient's Psychiatric Rehabilitation Progress

You can document psychiatric rehabilitation services, and track and review the progress of the patient's treatment plan.

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 Psychiatric Rehabilitation Progress (BH), and then select OK.
   Note: You can open the Psychiatric Rehabilitation Progress (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 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.
6. 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.
7. In the Individuals Present panel, document the details of the individuals present during the assessment.
8. In the Goals, Objectives, and Interventions Addressed Today panel, document the patient's goals, objectives, and interventions addressed on the current date.
9. 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.
10. Document the progress details of the patient's current assessments.
11. Document whether there are any new issues present on the current date.
12. Document the patient's assessment and diagnosis details.
13. Document the applicable signatures from the tasking supervisor or staff.
14. 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.
15. In the Charges panel, document the billing details.
16. Optional: Select No Billing for Service if there is no charge for the current date.
17. Select Generate Document.