Assess/Plan Section Tab

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Explanation of the Functional Section Tab

The information documented on the Functional section tab helps in determining the client’s needs and setting up goals and objectives that are an integral part of the recovery plan. Each panel on the Functional section tab is structured similarly. Items are listed and the question is asked of each item: Not clinically indicated (NI) and Current need area (CN). To understand the difference between NI and CN, look at this example of each in case of Individual care skills: NI - The client shaves and maintains a clean appearance. CN - The client does not want to wear any clothes. A field is available to right of each item in which evidence to justify whether NI or CN can be typed. To the right of this field are No and Yes options to answer Individual/family served desires change now for each item. None of the questions are mandatory. Enter Activities of Daily Living Assign Clinical Assessment of Addictive Behaviors Assign Clinical Assessment for Behavior Management Record Family and Social

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Intake Process for Comprehensive Assessment

The intake process is designed to be completed over several visits if needed. The Comprehensive Assessment templates can be accessed on a future encounter to finish the intake. If this documentation represents a new problem or the recurrence of an old problem, the New Intake button is used. When selected, a confirmation window states that you are about to clear data. Selecting Yes indicates that you are beginning a new episode of care. The historical data still exists in the past encounters. Start a New Intake Record the Client's Presenting Concerns Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Visit Types for Comprehensive Assessment

The Comp Assess tab can be found in the following Visit Types: Case Consultation Chart Abstraction Chart Update Developmental Testing - Extended Developmental Testing - Limited Family Consultation Group Home Visit Home Visit Hospital Consult Intake No Medical Services Intake with Medical Services Onsite Consult Psychiatric Diagnostic Evaluation Psychiatric Evaluation with Medical Services Psychological Testing Psychotherapy - Family without client Psychotherapy - Family & Client Psychotherapy - Family Group Psychotherapy - Group Psychotherapy - Individual Virtual Visit Telephone Virtual Visit Video Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter Treatment Recommendations

The Treatment Recommendations/Assessed Needs panel enables the delineation of assessed needs, their priority, their status, the date identified, the rationale for not addressing a particular need, and the date resolved. The priority, assessed need and status are required fields if this section is used. If no recommendations are indicated, select No additional recommendations clinically indicated. To enter an assessed need, click the Priority field to type a number. Free text an explanation in the Assessed Need field. In the Status field, select a value from the Need status list. Enter a date in the Identified field. If the need has been declined, deferred, or referred out, enter a Rationale. If the assessed need is resolved, enter the Resolved date. Enter other assessed needs if required. To manage existing assessments, highlight a row in the grid and click Update or Remove. To delete data from the related fields before it is saved to the grid, click Clear. Select any Further evaluatio

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® Adaptive Content Engine Help Enterprise 8.3.1

Comprehensive Assessment Template Set

The workflow of a comprehensive assessment is a set of five templates that enable you to perform a complete intake evaluation for either an adult or pediatric, Behavioral Health clients. The comprehensive assessment is meant to be completed by a clinician designated by the practice. This occurs during the agency’s intake process. From the Comp Assess tab is also known as the BH CA Presenting Concerns template. The following templates that make up the Comprehensive Assessment Template set are accessed through a section tab menu: Concerns Social Hx Bh Hx Functional Assess/Plan Visit Types for Comprehensive Assessment Access the BH CA Presenting Concerns Template Intake Process for Comprehensive Assessment Social Hx of a Comprehensive Assessment BH Hx Section Tab Overview Explanation of the Functional Section Tab Assess/Plan Section Tab Parent topic: Intake Visits for Behavioral Health