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Add Additional Notes
On the
Notes
panel, enter a
Narrative
.
In the
Results of the Psychiatric Rehabilitation Readiness Determination
field, click to enter a score and any other pertinent information.
Enter details in the
Strengths
field.
In the
Clinical, immediate and other service related needs
field, click to document the client's needs based on the referral information provided.
Use the
Rehabilitation aspirations
field to relate the client's goals and desired outcome.
Select
No
or
Yes
for
Admission indicated
and if
Yes
, enter a reason and/or disposition.
Referral information can also be entered in the field.
To order a referral for the client, click the
Referral
button to open the
My Plan
tabbed template on the
Referrals
tab.
Use the
Initial services
field to free-text the services and/or activities that are provided to the client to meet the individual’s identified needs.
Enter information about the family, household members, or significant others who are interviewed in the
Collaterals interviewed
field.
Add Additional Notes
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter Assessment and Diagnosis Details
Expand the Assessment/Diagnosis panel. If enabled, click the DSM IV link in the upper, right corner to launch the BH – DSM IV template. Note: The display of the link is set up on the Behavioral Health section of the Practice Configuration system template. In the Behavioral Health Diagnoses section, select any of the available links. In the Diagnostic description required field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. Add Status, Severity, Differential DX, and Impression.The out-of-the-box Severity picklist does not include Extreme or Persistent. These values can be added to the list in File Maintenance. Enter any required Specifiers by doing one of the following actions: Click the field to type a value. Click the My Phrases link to create a new sentence or part of a sentence. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User
NextGen Behavioral Health Suite Help 5.5
Document Information about Individuals Present during an Assessment
You can document details about the individuals present during the patient's assessment. On the assessment template, expand the Individuals Present panel. Select the contact from Contact Type. Information in POS Description and Code is filled in automatically. Select the reason for contact. Indicate whether the individual is present and, if not, enter the reason for the absence. If other individuals are present, select Others present, and then enter information about those individuals. To enter information about a support resource person, select Add. In the Guardian Info window, do the following: In the Patient Relationship/Support Role section, enter information about the relationship with the foster child. Enter the support person's role, name, and dates for the support period. In the Residence section, enter the primary and secondary addresses. Enter details about the primary and secondary communication and the representation timeframe. Select Save. The relationship details are saved
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Referrals for Psychiatric Rehabilitation
You can document referrals, treatment recommendations, assessed needs, and discharge planning for psychiatric rehabilitation patients. You can document the directed care plan and services that are provided as part of the psychiatric rehabilitation 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 Rehab Referral (BH), and then select OK. Note: You can open the Rehab Referral (BH) template from your Packet Navigation,or from the Templates module. For more information on configuring Packet Navigation, go to NextGen Healthcare Success Community, and download the Configuration Guide for NextGen® Behavioral Health Suite. 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. Document the general det
NextGen Behavioral Health Suite Help 5.5
Psychiatric Workflows
NextGen® Behavioral Health Suite provides the following Psychiatric workflows: Psychiatric Evaluation Psychiatric Progress Notes Psychiatric Notes Document the Patient's Initial Psychiatric Evaluation Summary As a psychiatrist, nurse practitioner (NPP), or other behavioral health professional, you can document an initial psychiatric assessment of the patient. Document the Patient's Psychiatric Progress Note You can document the patient's progress from the psychiatric evaluation. Finalize Documentation The Finalize (BH) template enables you to view today's assessments, today's orders, enter counseling and/or interpreter information, submit E&M codes, or select the No Billing for Service checkbox. Document the Patient's Psychiatric Notes You can document the psychiatric notes about the patient. Document the Patient's Referrals for Psychiatric Rehabilitation You can document referrals, treatment recommendations, assessed needs, and discharge planning for psychiatric rehabilitation patient
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document a Therapy Referral
You can select the Medications or Immunizations links at any time during the encounter to open the associated module. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. Open the Intake template, select the Family Practice specialty and Office Visit visit type, and then select My Plan.The My Plan window opens. Select the Referrals tab. The Referrals Order template opens. You can select the information icon to learn more about the Referrals Order template. On the Referrals tab, select the insurance provider. Enter the insurance policy number, and then select the referral type. In the To section, select Therapies/Rehabilitation, and do one of the following: Select a value from the resulting list. Select the upper blank row in the list to enter a therapy name in the field. Select the Location field and do one of the following: Select a value from the list. Select the upper blank row to enter a location in the field. To indicate if authorization is required,
Help Guide for NextGen® Enterprise PM 8
Submit New Referral Inquiry
To submit a New Referral Inquiry: Right-click and select New Referral from one of the defined access paths. The New Referral Entry appears. Complete the following required fields: Replace with table Patient Insurances Requesting Physician Referred To Entity Type Place of Service Complete the optional fields: Requesting Location (leave blank) Code Qualifier (leave blank) ID Code (leave blank) Reference Code Qualifier (leave blank) CPT4 ICD-CM Reference ID Code (leave blank) Number of Encounters Notes (not sent to payer but displays on response - 255-character limit) Select OK. The inquiry is now being processed. The Progress bar appears under Ready to Submit. When the submission is complete, the system displays the response in the Referral Result window. To print a copy of the eligibility response for your records, select the print option. Select Close. Note: Each time an inquiry is submitted and a response is received, a significant event is logged. When a response is received, a chart
