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, review and update the patient's medication details.
In the Mental Status Evaluation panel, enter the patient's mental health details.
To document the patient's mental health status systematically, you can select the Mental status exam link in the Mental Status Evaluation panel.
In the Risk Assessment panel, complete the corresponding risk assessment templates.
In the Past Risk and Alerts panel, document the patient's history of suicidal and self-injury risk.
In the Screening Tools panel, complete the corresponding screening questionnaires for the patient's mental health and substance addiction.
