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Document the Patient's Clinical Details Using the Short Integrated Note 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
.
Select
Short Integrated 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 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
Orders
panel, document the patient's lab, radiology, and medication orders.
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
Billing
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 Individuals Present during an Assessment
You can document details about the individuals present during the patient's assessment.
Document the Patient's Clinical Details Using the Short Integrated Note Template
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
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 Case Management Services in the Contact 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 Contact 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, 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 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 encou
NextGen Behavioral Health Suite Help 5.6
Document the Initial Screening 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 Screening 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, 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. Enter your plan and discussion on 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
NextGen Behavioral Health Suite Help 5.6
Document the Assessment and Billing Information
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 Assessment/Reassessment Billing (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, 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 Treatment Recommendations/Assessed Needs panel, document the recommended treatments and the patient's needs. Document the patient's assessment and diagnosis details. Document the applicable signatures from the tasking supervisor or staff. In the Time Entry Navigation sidebar
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Treatment Progress
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 Progress 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, 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 about 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
