Comprehensive Assessment Template Set

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 - Individualized Action Plan (IAP) Template

The Individualized Action Plan (IAP) template is the master treatment plan of care for the client. Following the Comprehensive Assessment exam, the Behavioral Health provider may choose to initiate an IAP. The IAP is completed in collaboration with the Behavioral Health client and a copy of the finished plan is usually signed by the client. The action plan template enables users to leverage electronic functionality by tying together the data across the client’s assessment, IAP, and Progress Note. Because this information is shared, the user is not repeatedly entering the same data. Visit Types for Individualized Action Plan Complete the IAP General Panel Document Assessed Needs, Goals, Objectives, and Interventions Enter Goal Information Record Objective Information Document Interventions, Methods, and Actions Other Functional Areas Not Applicable/Methadone Treatment Transition/Discharge Criteria Panel Enter Document Signatures Parent topic: Intake Visits for Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Access the BH CA Presenting Concerns Template

To complete a comprehensive assessment as part of the intake process, enter the following information on the Home Page - Behavioral Health template: In the Visit Type field, select a value from the list. Select Intake no Medical Services or any of the other Visit Types listed in the above section of this User Guide. Click the Comp Assess tab to launch the BH CA Presenting Concerns template. The Concerns section tab is highlighted to indicate that you are on the w template. The abbreviations presented in the name of the template refer to Behavioral Health (BH) and Comprehensive Assessment (CA). Parent topic: Comprehensive Assessment Template Set

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

Social Hx of a Comprehensive Assessment

The Social Hx section tab enables you to continue with the Comprehensive Assessment and document the client's living situation, development history, social supports and more. Maintain Family Data for the Client Document the Client's Living Situation Enter Developmental History Information Document Sexual Issues Document Social Supports Record the Client's Legal Issues Document the Education History for an Adult Client Enter Education Information for a Child/Adolescent Document the Patient's Employment Status You can document the patient's employment status for Behavioral Health by using the BH CA Social History template. Document Military Service Maintain a Record of the Client's Trauma History Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Intake Visits for Behavioral Health

Intake visits are where the Comprehensive Assessment exam, including a substance use assessment and mental status exam are documented. Users can also choose to document an Individualized Action Plan (IAP), screening or admission note, or a psychiatric evaluation from an intake-based encounter. There are two types of Intake visits: with or without medical services. Intake No Medical Services can be used by anyone at the practice. Intake with Medical Services is designed to be used by providers who may be performing a physical exam and/or prescribing pharmaceuticals. Home Page - Behavioral Health Template Document a Generalized Anxiety Disorder - 7 Screening Comprehensive Assessment Template Set BH - Brief Assessment Template BH - Individualized Action Plan (IAP) Template BH - Psychiatric Evaluation Parent topic: Behavioral Health

Comprehensive Assessment Template Set

Recommendations

BH - Brief Assessment Template

BH - Individualized Action Plan (IAP) Template

Access the BH CA Presenting Concerns Template

Intake Process for Comprehensive Assessment

Social Hx of a Comprehensive Assessment

Intake Visits for Behavioral Health

Comprehensive Assessment Template Set

BH - Brief Assessment Template

BH - Individualized Action Plan (IAP) Template

Access the BH CA Presenting Concerns Template

Intake Process for Comprehensive Assessment

Social Hx of a Comprehensive Assessment

Intake Visits for Behavioral Health