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Document Client's Affect and Mood
Open the
BH - Residential Shift Note
template and expand the
Client Affect and Mood
panel.
In the
Client affect
field:
Click to select one or more pre-configured values from the list and click
OK
.
Select the top blank row in the list and click
OK
to type in the field.
In the
Client mood
field:
Click to choose from the multiple selection list.
Select the top blank row to free text an entry directly in the field.
Enter
Comments
if required.
Document Client's Affect and Mood
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Sign Off on Shift Notes
Signing off in the Signatures panel indicates that the entered shift notes have been reviewed. The grid on the Signatures panel does not copy forward and is not shared onto any other template. Open the BH - Residential Shift Note template and expand the Signatures panel. Place a check mark next to the label(s) that apply. When a label is selected, the Name and Date fills the corresponding fields. If needed, enter or modify any Credentials to further identify a signature. Note: The practice can pre-set credentials for users in File Maintenance. To indicate that a signature is not applicable and clear the fields of anything that may have been entered in the same row, select the N/A option. To forward the template to the next person in line to sign off on the documented shift note, click Send Task. If your signature does not fall under the pre-set options, use the Additional Staff section. Name and Date are required fields. To enter additional information, click the Comments field. To com
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Provide Instructions for the Next Shift
On the Shift Plan panel of the BH - Residential Shift Note template, in the Plan field, do one of the following: Click to select a value from the list. Select the blank row in the list to free text in the field. Use the My Phrases functionality. In the Referred to field, click to select a description of the professional from the list or the top, blank row to manually enter a value. Enter the Reason for the referral. Select No or Yes for Homework given this shift. If Yes, do one of the following actions: Click to free text in the field. Use the My Phrases functionality. Data entered here populates in the Last homework given field at the top of the template. Parent topic: Shift Note Template Set
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record Tracking Details for the Current Shift
Every field on the Client Tracking panel is required. The grid on this panel filters to the current encounter date only. All historical data appears in the BH - Residential Administration template. Open the BH - Residential Shift Note template and expand the Client Tracking panel. Enter the Date. In the Time field, click one of the following: Drop-down arrow to open a Time Entry window. Click the Clock button to enter the current time. In the field to enter or edit the time. In the Location field, click to select a value from the configurable list. For more information on how to modify customizable picklists, go to NextGen Healthcare Success Community, and download the Custom DB Picklists System Template for NextGen® Adaptive Content Engine. Click the Status field to enter a value configured by the practice. To enter additional information, click the Comments field. Click Add to populate the information in the grid. To filter the grid, select All or Current Admission To modify a grid r
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record and View All Client Calls and Visits on Shift Note
Open the BH - Residential Shift Note template and expand the Client Call/Visit Log panel. Select Call or Visit for Type, a required field. Click the Date field to enter the required value in the calendar window. Enter the caller or visitor information. The Name(s) field displays a list of names from the BH - Residential Administration, Authorized values. Click Close. To enter additional information, click the Comments field. Click Add to populate the information in the grid. To filter the grid, select All, Call, Visit or Current Admission (default filter). Parent topic: Shift Note Template Set
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Multiple Shifts
On the BH - Residential Shift Note template, verify the client name and encounter date are correct, then click Patient Name and Encounter Date are correct. Click the appropriate tab to indicate the shift you are documenting: Shift 1, Shift 2, or Shift 3. In the required Shift start field, enter the shift start time. Note: An alert fires if the user tries to generate a document at the end of their shift without both the start and end time fields populated. Enter the Shift end time. The Duration, read-only field automatically calculates. Review the Bed Board section, which includes a grid with information for the open chart only. This grid shares with the Residential Bed Board practice template. It reveals all of the data available on the client regardless of admission or discharge dates. Parent topic: Shift Note Template Set
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter Goals, Objectives and Interventions to be Addressed in the Current Shift
The first panel on the BH - Residential Shift Note template documents the goals/objectives and interventions addressed in the current shift. Required fields are marked with an asterisk. Open the BH - Residential Shift Note template and expand the Goals/Objectives and Interventions Addressed this Shift panel. Under the first section, click the Addressed diagnosis field to open an associated list.The Diagnosis code field automatically populates and vice versa if the user decides to use the code field to enter the data. The Addressed Diagnosis or the Diagnosis code fields are not required and launch an Addressed Diagnosis list that pulls from the data previously entered in the Assessment/Diagnosis grid on other templates in the Behavioral Health template set. Click the required Goal today field to open a list of new, continued, or revised goals entered on either of the Individualized Action Plan templates. In the Objective today, required field, click to select a value from a list of all
