Document the Patient's Strengths, Needs, and Cultural Discovery
- 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 SNCD (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.
- In the Individuals Present panel, document about the individuals present during the assessment.
- 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.
- In the SNCD panel, document the patient's involvement with the family, community, training, legal, financial, and relationships.
- Document the patient's assessment and diagnosis details.
- 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.