Add an Existing Diagnosis to the Current Encounter

NextGen Behavioral Health Suite Help 5.6

Add Diagnostic Details

In the Assessment/Diagnosis panel, confirm the assessment selected displays in the Description details and ICD Code field. If not, select the assessment in the grid to fill in the details. Add Status, Severity, Differential Dx, and Impression. To enter specifiers in the Specifiers field, do one of the following: Select in the field and enter free text. Select the My Phrases link and select a phrase from the list. If applicable, select Present on Admission and then select a description from the list. To indicate the diagnosis is chronic, add the diagnosis to the client’s clinical problems list, and/or add the assessment to my tracked problems, select the respective checkbox. Select Add To Grid. The information displays in the grid. To add psychosocial stressors, select the Psychosocial Stressors link. To add referrals, select the Referrals link. To reorder the diagnoses, select Sort. To update a diagnosis, select the diagnosis in the grid, modify the details, and select Update. Parent t

NextGen Behavioral Health Suite Help 5.6

Sort Assessment Order

For billing or documentation purposes, it may be necessary to modify the order in which the assessments are displayed on your documentation. From the Assessment/Diagnosis panel, select Sort. The Reorder Assessments window opens. Reorder Assessments window From the Existing Sort Order grid, select the assessment to display first in the list. The assessment displays as #1 in the New Sort Order grid. From the Existing Sort Order grid, select the assessment to display next in the list. The assessment displays as #2 in the New Sort Order grid. Repeat step 3 until all assessments on the encounter display correctly in the list. Reorder Assessments window To move the remaining assessments without changing the order to the New Sort Order grid, select Move Remaining. To remove an assessment added to the New Sort Order grid in error, use either Undo Last or Undo All. Select Save & Close. Parent topic: Behavioral Health Assessment and Diagnosis

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Complete the Diagnoses Section for Transfer/Discharge

In the Behavioral Health Diagnoses section, select any of the available links: Diagnosis Code Lookup Add Common Assessment Mandated Care Coordination In the required Diagnostic description field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. In the Status field, click to select a value from the list. If appropriate, enter a Severity. If needed, enter a Differential dx, and/or Impression. To enter Specifiers, click one of the following: In the field to manually enter any required values The My Phrases link. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. For chronic conditions, select the option to Mark diagnosis as chronic. Select the options to add the assessment to the Clinical problems, My tracked problems, and/or My favorites where applicable. Click Add To Grid. In the Physical Hea

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document an Assessment

You can filter the grids on the Assessments tab. For example, in the Billing Diagnosis History section, selecting the Show Chronic only checkbox displays diagnoses that are not acute. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. Open the Intake template, select the specialty as Family Practice and the visit type as Office Visit, and then select My Plan. The My Plan window opens. Select the Assessments tab.The Add or Update Assessment template opens. Select the Add common assessment link.The Common assessment window opens based on specialty, gender, and age of the patient. Select an assessment and then select Save & Close.The Today's Assessment grid displays the diagnoses details. If your practice requires a status for the diagnosis, you must select the status. If a working assessment exists, it remains selected in the Today's Assessment grid. To update the working assessment, select the diagnosis in the Today's Assessment grid. Optional: On the Add

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter Assessment and Diagnosis Details

Expand the Assessment/Diagnosis panel. If enabled, click the DSM IV link in the upper, right corner to launch the BH – DSM IV template. Note: The display of the link is set up on the Behavioral Health section of the Practice Configuration system template. In the Behavioral Health Diagnoses section, select any of the available links. In the Diagnostic description required field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. Add Status, Severity, Differential DX, and Impression.The out-of-the-box Severity picklist does not include Extreme or Persistent. These values can be added to the list in File Maintenance. Enter any required Specifiers by doing one of the following actions: Click the field to type a value. Click the My Phrases link to create a new sentence or part of a sentence. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Adding a Tracked Diagnosis from the Patient's Problem List to the ICD Billing List

You can add a diagnosis from a patient's problem list to ICD billing list for that patient. A chronic or tracked condition diagnosis from the patient's problem list can be added to the ICD billing list. This causes the diagnosis to be associated with an ICD billing code, and enables it to be associated with a care guideline. Open NextGen® Enterprise EHR. Select the Care Guidelines link on any of the main template.The Care Guidelines template opens. Select Add/Update in the Care Guidelines panel.The Activate Care Guidelines template opens. Expand the Problem List panel, do the following: Select the Show chronic checkbox to display chronic problems only. Select the Show my tracked problems checkbox to display only those diagnoses that have been assigned to the patient’s tracked problems list. Select the No active problem checkbox, to indicate that the patient currently does not have an active problem. Problem List Note: To open the Problems module, select Add or Edit. To reload the Probl

Add an Existing Diagnosis to the Current Encounter

Recommendations

Add Diagnostic Details

Sort Assessment Order

Complete the Diagnoses Section for Transfer/Discharge

Document an Assessment

Enter Assessment and Diagnosis Details

Adding a Tracked Diagnosis from the Patient's Problem List to the ICD Billing List

Add an Existing Diagnosis to the Current Encounter

Add Diagnostic Details

Sort Assessment Order

Complete the Diagnoses Section for Transfer/Discharge

Document an Assessment

Enter Assessment and Diagnosis Details

Adding a Tracked Diagnosis from the Patient's Problem List to the ICD Billing List