Nursing and MA Documentation

Template	Designated Use
Short Integrated Note (BH)	Medical assistant or similar supporting staff to document clinical information
Nursing Note (BH)	Nursing staff to document nursing services
Integrated Note (BH)	Medical assistant or similar supporting staff to document nursing services, including updates or changes to a client's review of systems or physical exam
Integrated Nursing Note (BH)	Nursing staff to document nursing services, including updates or changes to a client's review of systems or physical exam

NextGen Behavioral Health Suite Help 5.5

Individual Visit Workflows for Behavioral Health

Individual visit workflows for NextGen® Behavioral Health Suite are found in the following section. Document the Assessment and Billing Information You can document the billing details for an assessment service even without completing a full comprehensive assessment. Document the Adult Recovery Team Meeting Note You can document the details of the meeting conducted by the adult recovery team. Document a Child and Family Team Meeting Note You can document the patient's details from the child and family team meeting. Document the Patient's Case Management Services in the Contact Note You can document the patient's billing and case management details. Document Care Coordination You can document the caregivers' coordination towards the patient's care. Document Client Requests for Services You can document client request for services and meet the routine care needs and initial evaluation measures. Document a Physician Order You can document the orders requested by the patient's physicians.

NextGen Behavioral Health Suite Help 5.5

Document Patient's Mental Health Details Using the Brief Assessment 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. From the list, select Brief Assessment (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether you have discussed confidentiality and obtained patient's consent for the care. To document the patient's past medical history, select the History Summary link. In the Presenting Concerns panel, do one of the following actions in the Written HPI narrative field: Enter the patient's symptoms and presenting issues that prompted a visit to the office. Use the My Phrases link to select the details for the visit. In the Substance Use/Addictive Behavior panel, select the patient's addiction details to substances. Select the patient's current experiences on physical and domestic violence and other trauma details in the Trauma History panel. Enter the patient's mental status evaluation findings. Comp

NextGen Behavioral Health Suite Help 5.5

Managing Patient's Addiction Details

Your practice can configure the Addiction Severity Index (BH) to be accessible from your Packet Navigation or you can access the template from the Templates module . For more information, go to NextGen Healthcare Success Community and download the Configuration Guide for NextGen® Behavioral Health Suite. On the General Information and Severity Profile panels, you can select the information icon for tips on using the specific panels during the interview. After documenting the potential problem areas for the client, you can submit charges for the encounter or select the No Billing for Service checkbox. By selecting Addiction Severity Index, you can generate the Addiction Severity Index document, which displays the documented data for the patient. Select Program, Specialty, and Visit Type You can document the patient's billing and case management details. Document General Addiction Severity Index Information Severity Profile Assessment and Diagnosis Functionality Task Supervisor/Staff for

NextGen Behavioral Health Suite Help 5.5

Crisis Mental Health Services

Crisis Mental Health Services are a set of templates and workflows meant to assist the client with effective problem-solving strategies to resolve the critical situation (if possible) or to cope with the problem as it continues. The templates included in the NextGen® Behavioral Health Suite Crisis Mental Health Services are: Crisis Contact Note (BH) Crisis Treatment Plan (BH) Relapse Prevention Plan (BH) Psychiatric Advance Directive (BH) Document Crisis Contact Details You can document the patient's crisis intervention and stabilization services. Document Crisis Treatment Plan Details You can document a detailed assessment on the patient's crisis and plan the treatment course. Document the Patient's Relapse Prevention Plan You can document the plan for preventing the patient's relapse and avoiding crises. Document the Patient's Psychiatric Advance Directives You can document the patient's preferences about the mental treatment in the event that the patient becomes unable to make such

NextGen Behavioral Health Suite Help 5.5

Residential Services Workflows

Residential Services workflows focus on documentation related to clients living in a treatment facility. Behavioral Health practices can record the admission of clients and maintain an ongoing record of a client's treatment. NextGen® Behavioral Health Suite provides the following Residential Services workflows: Residential Administration Bed Board Residential Shift Note template set Detoxification Monitoring Medication Administration Record (MAR) template set Residential Discharge Document Administration Details for the Patient's Residential Services Upon patient enrollment in a residential program, you can document the patient's specific program and dependents, and document their personal belongings and medications. Bed Board Bed Board enables agencies to track and manage bed assignments and provides key insights into each patient. Document the Clinician's Shift Notes As a clinician staff, you can document multiple shifts within the same note. Detoxification Monitoring The Detoxificat

NextGen Behavioral Health Suite Help 5.5

Discharge Summary

Your practice can configure the templates to be accessed from your Packet Navigation or you can access the template from the Templates module Template Icon. For more information, go to NextGen Healthcare Success Community and download the Configuration Guide for NextGen® Behavioral Health Suite. Document Discharge Summary You can document the patient's discharge details from a program. 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. Parent topic: Using NextGen Behavioral Health Suite

Nursing and MA Documentation

Recommendations

Individual Visit Workflows for Behavioral Health

Document Patient's Mental Health Details Using the Brief Assessment Template

Managing Patient's Addiction Details

Crisis Mental Health Services

Residential Services Workflows

Discharge Summary

Individual Visit Workflows for Behavioral Health

Document Patient's Mental Health Details Using the Brief Assessment Template

Managing Patient's Addiction Details

Crisis Mental Health Services

Residential Services Workflows

Discharge Summary