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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.
Complete an exam on the patient's behavior and mental condition by selecting the
Mental Status Exam
link in the
Mental Status Evaluation
panel.
Complete the risk assessment templates in the
Risk Assessment
panel.
Document Information about Individuals Present during an Assessment
You can document details about the individuals present during the patient's assessment.
Add Patient's Need, Goal, Objective, and Intervention Information
You can manage the needs, goals, objectives, and interventions details of a patient.
Assessment and Diagnosis Functionality
You can enter assessment information for the current encounter by using the
Assessment/Diagnosis
panel.
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.
Submit Charges
You can use the Charges panel to submit a charge for the billing process.
Document Patient's Mental Health Details Using the Brief Assessment Template
NextGen Behavioral Health Suite Help 5.6
Document Patient's Trauma History using the LEC-5 Interview Template
In NextGen® Enterprise EHR, in Patient History, select the Templates button. The Select Template window opens. On the Medical Records tab, select All. From the list, select LEC-5 Interview (BH), and then select OK. Select the program, specialty, and visit type for the patient. In the Rate Emotional Abuse Severity panel, enter the rating after completing all the questions on the patient's emotional status. In the Rate Physical Abuse Severity panel, enter the rating after completing all the questions on the patient's physical status. In the Rate Sexual Assault or Other Uncomfortable Sexual Experience Severity panel, enter the rating after completing all the questions on the patient's sexual assault experiences. In the Rate Other Stressful Event Severity panel, document the patient's exposure to other stressful events such as war, life-threatening illness, sudden violent death, or serious injury you have caused to someone else. In the Event Rating and Summation panel, document the overall
NextGen Behavioral Health Suite Help 5.6
Document Integrated Service Plan Information
In NextGen® Enterprise EHR, in Patient History, select the Templates button. The Select Template window opens. On the Medical Records tab, select All. From the list, select Integrated Service Plan (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether the treatment program is the initial assessment or an annual update to an existing assessment. Expand the Family Vision/Treatment Involvement panel, and enter details about the patient's treatment program. In the Support Resources section, select Add to enter the patient's guardian details. In the Person's Strengths section, select the patient's strengths, and then select Add. Enter details in the Additional Services/Discharge Plan panel. Add the screening tools and the corresponding assessment scores to the current encounter. Note: You can open the Screening Tools template to complete more assessments by selecting the Screening Tools link. Select the expected discharge date for the patient
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Intake Notes Using the Comprehensive Assessment Templates
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 Comp Assess - Concerns, and then select OK. Select the program, specialty, and visit type for the patient. Complete the assessment in the Concerns tab. Complete the assessment in the Social Hx tab. Complete the assessment in the BH Hx tab. Complete the assessment in the Asses/Plan tab. Select Generate Document. Document the Patient's Presenting Concerns You can document a patient's initial or annual assessment details and the presenting concerns. Document the Patient's Social Support Information You can document the patient's living situation, development history, and other social support details. Document the Patient's Mental Health and Risk Assessment Information You can use various screening tools to document the patient's mental health history, substance use, and risk assessment . Document the Summary of th
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Comprehensive Clinical and Nursing Details
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 Nursing Note (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. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Vital Signs panel, select Add to capture the patient's vitals. In the New Issues panel, document the patient's new issues and the status. In the Risk Assessment panel, document the patient's risks towards suicide or danger to self or properties. Document whether the patient takes medication as prescribed. Document the patient's alleries and their current status. Enter your plan and discussion on the patient's treatment. Note: You can select Copy Forward to copy existing details from another encounte
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Initial Psychiatric Evaluation Summary
As a psychiatrist, nurse practitioner (NPP), or other behavioral health professional, you can document an initial psychiatric assessment of the patient. It is important to note that you can prescribe medications during the psychiatric evaluation. Also, the EM Coding button opens the Finalize template, which enables you to submit billing codes. 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 Psych Eval (BH), and then select OK. Note: You can open the Psych Eval (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. 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 enco
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Nursing Services
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 Nursing Note (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. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Vital Signs panel, select Add to capture the patient's vitals. In the New Issues panel, document the patient's new issues and the status. In the Risk Assessment panel, document the patient's risks towards suicide or danger to self or properties. Document whether the patient takes medication as prescribed. Document the patient's alleries and their current status. Enter your plan and discussion on the patient's treatment. Note: You can select Copy Forward to copy existing details from another encounte
