Document the Patient's Summary Progress Note
- 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 IDD Summary Progress Note (BH), and then select OK.
Note: You can open the IDD Summary Progress Note (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.
- 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 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 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.
- 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.