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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
.
Document the Summary of the Patient's Assessments
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Social Support 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 - Social Hx, and then select OK. In the Living Situation panel, document the patient's current living details such as address, residential treatment, household composition, and risk assessment. In the Family Information panel, document details about the patient's family members, family history of mental illness or substance addiction, and the emotions attached to the family members. In the Development panel, document the patient's motor and sensory development history. In the Abuse/Sexual Risk Behavior panel, document the details about any physical, sexual, or emotional abuse the patient has experienced. Note: Client answers are copied forward from the previous comp assessment. You can select My Phrases to document and update the answers. In the Social Support panel, document details about the suppo
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Presenting Concerns
You can document a patient's initial or annual assessment details and the presenting concerns. 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.The Comp Assessment - Concerns window opens with the date of the last comp assessment. Document whether the assessment is the initial assessment or an annual update to an existing assessment. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Presenting Concerns panel, enter the details of the patient's current concerns and the required help. 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
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 Transfer Summary
You can document the patient's transfer details from one program to another. 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 Transfer Summary (BH), and then select OK. Select the program, specialty, and visit type. Select the patient's discharge date. To close the selected program for the patient, select the status of the patient's treatment in the program. In the Assessment/Diagnosis panel, document the patient's active diagnosis and assessment details. In the Transfer Summary panel, document the treatment details, post-transfer support details, risk details, and the reason for the patient's transfer. In the Transfer Plan panel, document the patient's active medications and transfer plans and instructions. Select Generate Document. Assessment and Diagnosis Functionality You can enter assessment information for the current encounter by using the Assessment/Diagnosis panel.
