BH - Psychopharm Template

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

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

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

BH - Individual Counsel/Psych Prog Note Template

The BH - Individual Counsel/Psych Prog Note template enables you to document individual counseling services and the client's progress or the lack thereof. Any risk assessment, goals, objectives, or assessment data that was entered previously on the Comprehensive Assessment template set populates in the panels found on the Progress Note tab. You can document new issues and make updates to the goals, objectives and interventions. Use the Behavioral health billing section to submit billable service codes to the Superbill. The Progress Note tab can be a stand-alone template or used in conjunction with the other tabs or links. Enter Program Name Record Individuals Present Update the Client's Current Assessment Record a Risk Assessment Record New Issues Enter Goals, Objectives, and Interventions Addressed Today Document Plan and Additional Information Enter Assessment and Diagnosis Details Sign the Behavioral Health Document Complete Behavioral Health Billing Parent topic: Individual Visit W

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

BH - Psychiatric Evaluation

The Psychiatry Eval tab is designed to be a stand-alone template for a psychiatrist, nurse practitioner (NPP), or other Behavioral Health professional who is qualified to conduct and document an initial psychiatric assessment of the client. The information on the Psychiatry Eval tab overlaps with the data recorded on the Comp Assess tab. Of the 17 panels on the tab, only two (Physical Health History and Issues for Children/Adolescents) are not identical to the corresponding panels on the Comprehensive Assessment. If a Comprehensive Assessment was completed for this client prior to the Psychiatric Evaluation, much of the information is filled. It is important to note that medications can be prescribed during the psychiatric evaluation. The Behavioral health billing section is available at the bottom of the Psychiatry Eval and Progress Note tabs to submit billing codes. Some providers may want to use the SOAP tab to document additional elements of the physical exam. For more information

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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

BH - Psychopharm Template

Recommendations

Nurse's Progress Note (Long)

Nurse's Progress Note (Short)

BH - Brief Assessment Template

BH - Individual Counsel/Psych Prog Note Template

BH - Psychiatric Evaluation

BH - Contact Note Template

Nurse's Progress Note (Long)

Nurse's Progress Note (Short)

BH - Brief Assessment Template

BH - Individual Counsel/Psych Prog Note Template

BH - Psychiatric Evaluation

BH - Contact Note Template