Document Information about the Patient's Skill Assessment
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 Functional Skills Assessment (BH), and then select OK.
Note: You can open the IDD Functional Skills Assessment (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.
In the Assessed Needs, Goals, Objectives, and Interventions panel, document the patient's needs, goals, objectives, and interventions addressed on the current date.
Enter the summary of your discussion for the current date.
In the Functional Skills and Behavioral Assessment panel, document the patient's functional skills and the patient's family's agreement on the clinical services required to attain a specific skill.
Document the patient's addiction to substance usage behavior.
Document the patient's trauma history details.
Document the patient's mental status evaluation details.
Document the patient's homicidal and suicidal risk assessment details.
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 the Patient's Skill Assessment
