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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 the Patient's Assessments
You can document your plans for medications and diagnoses based on the patient's assessments.
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 the Patient's Intake Notes Using the Comprehensive Assessment Templates
NextGen Behavioral Health Suite Help 5.6
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 5.6
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 You can enter assessment
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
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 5.6
Document the Summary of the Patient's Assessments
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 - Assess/Plan, and then select OK. In the Life Goals, Strengths, Abilities and Barriers panel, enter the details of the patient's life goals, strengths, abilities, and barriers. In the Barriers to Care panel, document the obstacles to the patient's care. In the Service panel, enter the patient's care preferences and environmental support details. In the Clinical Formulation/Interpretative panel, document the patient's clinical summary. In the Treatment Recommendations/Assessed Needs panel, document recommendations for the patient's treatment and follow-up evaluations. Select Generate Document. Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Mental Health and Risk Assessment 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. From the list, select Comp Assess - BH Hx, and then select OK. To document the patient's medical and surgical details in the Past Medical/Surgical panel, select Add. Note: To document the patient's mental and physical health details, you can select the corresponding links in the Past Medical/Surgical panel. In the Substance Use/Addictive Behavior History panel, document the details about the patient's addiction to substance use. Note: You can click the Substance Use Assessment link to open the Substance Use Assess (BH) template. If there is no data available about the patient's substance use, you can select the No addictive behavior reported checkbox. In the Mental Health and Addiction Treatment Service panel, document the patient's treatment details about their mental health and substance use. In the Medication Information panel, r
