BH - Individual Counsel/Psych Prog Note Template

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Nurse's Progress Note (Long)

While the long and short notes were primarily designed for nurses working within a practice that provides psychiatric medication management, there are many other instances where using these templates would be appropriate. The BH - Nursing Note template (long note) should be used when it is apparent that there has been a significant change in the client's status. The long version of the template enables the documentation of vital signs and other medication concerns that may need to be conveyed to the psychiatric prescriber. Both versions of the nursing note are available from the navigation bar. Enter the Program Name Record Vital Signs for the Nurse Progress Note Document Individuals Present Enter an Interim Update Record New Issues Update the Client's Current Assessment Record a Risk Assessment Document Medication Information Enter Patient Allergy Data Enter Goals, Objectives and Interventions Addressed Today Enter Plan of Care and Additional Information Enter Assessment and Diagnosis

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

BH - Contact Note Template

Use the BH - Contact Note template to document billable treatment contacts with the client. This includes goal sessions with Personalized Recovery Oriented Services (PROS), case management, residential programs, and Permanent Housing Programs (PHP). The BH - Contact Note template may be used, for example, by a case manager reviewing an Individualized Recovery Plan (IRP) with a client. This information connects to the standard objectives and interventions to assist in the overall care of the Behavioral Health client. These billable encounters must include the staff’s interventions and/or services provided and the individual’s response to those interventions. Visit Types for the BH - Contact Note Enter the Program Name Document Individuals Present Record New Issues Enter Goals/Objectives and Interventions Addressed Today Enter Assessment and Diagnosis Details Sign the Behavioral Health Document Finalize Behavioral Health Billing Parent topic: Individual Visit Workflows for Behavioral Hea

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Nurse's Progress Note (Short)

The BH - Nursing Note Short template is a quick solution to document an encounter for a client who does not have any major changes since their last visit. The shortened version of the progress note includes the following panels: Program Name Vital Signs Individuals Present New Issues Goals, Objectives, and Interventions Addressed Today Assessment/Diagnosis Plan and Additional Information Signatures The Behavioral health billing section is available at the bottom of the BH - Nursing Note Short template. Enter the Program Name Record Vital Signs for the Nurse Progress Note Document Individuals Present Record New Issues Enter Goals, Objectives and Interventions Addressed Today Enter Assessment and Diagnosis Details Enter Plan of Care and Additional Information Sign the Behavioral Health Document Finalize Billing for Nurse Notes Parent topic: Behavioral Health Medication Management

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

BH - Brief Assessment Template

The BH- Brief Assessment template enables providers, case workers and social workers, to document on an abridged version of the Comprehensive Assessment template set. Because a comprehensive exam takes a significant amount of time (more than a single client visit), the BH - Brief Assessment template can be used to complete the evaluation during one encounter. Start a New Intake for a Brief Assessment Record the Client's Presenting Concerns Brief Assess Histories Panel Record Substance Use and Addictive Behavior Histories Enter Tobacco Usage Add Trauma History on the Brief Assess Record Mental Status Exam Information Record a Risk Assessment Enter Assessment and Diagnosis Details Enter Treatment Plan Information Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Intake Visits for Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Screening and Admission Visit Workflow

The BH - Screening/Admission Note template is used to document information that a program or Emergency Room might need for their initial evaluation of a client. Information gathered here is the basis for a summarization of the services and possible interventions that are initially provided to the client. Generally, this is completed by the non-clinical staff at the practice and can be done separately from a Comprehensive Assessment exam. The BH - Screening/Admission Note template can be accessed at any time during an encounter by selecting Other Templates from the bottom section of the navigation bar. Document Admission Data Document Referral Source Enter Assessment and Diagnosis Details Add Additional Notes Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

The BH - IAP Review/Revision Template

The BH - IAP Revision/Review template is used to document progress or lack thereof and demonstrates evidence and/or rationale for the amendment of treatment goals and objectives in the Individual Action Plan (IAP). The system automatically pulls forward data from the last IAP or IAP review to the current encounter. Use this template to update or modify the IAP in any of the following ways: Revisions – work with the client to add a new goal; change goals, objectives, or interventions; or to change the frequency or duration of services Reviews – record the progress of the client, therefore facilitating the identification and tracking of treatment goals and objectives Visit Types for the BH - IAP Review/Revision Template Start an IAP Revision/Review Document Assessed Needs, Goals, Objectives, and Interventions Add a New Goal for IAP Reviews Document Interventions for IAP Reviews Enter Methadone and Assertive Community Treatment Program Information Record Transition/Discharge Criteria Ente

BH - Individual Counsel/Psych Prog Note Template

Recommendations

Nurse's Progress Note (Long)

BH - Contact Note Template

Nurse's Progress Note (Short)

BH - Brief Assessment Template

Screening and Admission Visit Workflow

The BH - IAP Review/Revision Template

BH - Individual Counsel/Psych Prog Note Template

Nurse's Progress Note (Long)

BH - Contact Note Template

Nurse's Progress Note (Short)

BH - Brief Assessment Template

Screening and Admission Visit Workflow

The BH - IAP Review/Revision Template