Document the Patient's Strengths, Needs, and Cultural Discovery
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 SNCD (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.
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 encounter to the current encounter.
In the SNCD panel, document the patient's involvement with the family, community, training, legal, financial, and relationships.
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.
