Document Functional Status Assessment for Chronic Conditions

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Functional and Cognitive Assessments

You can document a patient's functional and cognitive assessments in the Functional and Cognitive Assessment Status panel. The data entered in the Functional and Cognitive Assessment Status panel is shared with the Health Promotion Plan, Medicare Preventive HPI, Screening Summary, and Care Plan templates to measure compliance and for surveillance reporting. Open NextGen® Enterprise EHR. Open the Intake template. Expand the Vital Signs panel, and then select the Health Promotion Plan link. The Health Promotion Plan template opens. Expand the Functional and Cognitive Assessment Status panel. Functional and Cognitive Assessment Status For Functional Status and Cognitive Status, do the following: If there is no change in the functional status of the patient, select No Change. If there is a change in the functional status or cognitive status of the patient, select Change. Select the Status field, and select the appropriate option from the list. Enter the assessment method and used method. T

NextGen Behavioral Health Suite Help 5.6

Document Patient's Mental Health Details Using the Brief Assessment Template

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 Brief Assessment (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether you have discussed confidentiality and obtained patient's consent for the care. To document the patient's past medical history, select the History Summary link. In the Presenting Concerns panel, do one of the following actions in the Written HPI narrative field: Enter the patient's symptoms and presenting issues that prompted a visit to the office. Use the My Phrases link to select the details for the visit. In the Substance Use/Addictive Behavior panel, select the patient's addiction details to substances. Select the patient's current experiences on physical and domestic violence and other trauma details in the Trauma History panel. Enter the patient's mental status evaluation findings. Comp

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document an Assessment

You can filter the grids on the Assessments tab. For example, in the Billing Diagnosis History section, selecting the Show Chronic only checkbox displays diagnoses that are not acute. Open NextGen® Enterprise EHR. Open a patient's record, and then open an encounter. Open the Intake template, select the specialty as Family Practice and the visit type as Office Visit, and then select My Plan. The My Plan window opens. Select the Assessments tab.The Add or Update Assessment template opens. Select the Add common assessment link.The Common assessment window opens based on specialty, gender, and age of the patient. Select an assessment and then select Save & Close.The Today's Assessment grid displays the diagnoses details. If your practice requires a status for the diagnosis, you must select the status. If a working assessment exists, it remains selected in the Today's Assessment grid. To update the working assessment, select the diagnosis in the Today's Assessment grid. Optional: On the Add

NextGen Behavioral Health Suite Help 5.6

Document the Patient's Mental Health and Risk Assessment Information

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 - BH Hx, and then select OK. To document the patient's medical and surgical details in the Past Medical/Surgical panel, select Add. Note: To document the patient's mental and physical health details, you can select the corresponding links in the Past Medical/Surgical panel. In the Substance Use/Addictive Behavior History panel, document the details about the patient's addiction to substance use. Note: You can click the Substance Use Assessment link to open the Substance Use Assess (BH) template. If there is no data available about the patient's substance use, you can select the No addictive behavior reported checkbox. In the Mental Health and Addiction Treatment Service panel, document the patient's treatment details about their mental health and substance use. In the Medication Information panel, r

NextGen Behavioral Health Suite Help 5.6

Document Information about the Patient's Skill Assessment

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select IDD Functional Skills Assessment (BH), and then select OK. Note: You can open the IDD Functional Skills Assessment (BH) template from your Packet Navigation, or from the Templates module. For more information on configuring Packet Navigation, go to NextGen Healthcare Success Community, and download the Configuration Guide for NextGen® Behavioral Health Suite. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Individuals Present panel, document the details of the individuals present d

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Title X 2.0 Template Overview

The Title X 2.0 template displays all the Title X 2.0 clinical information recorded for a patient during a family planning encounter. You can review the present and previously recorded patient details for Family Planning Annual Report (FPAR) 2.0. The patient’s recorded Title X 2.0 information is categorized into various panels, such as General, Social History, Confidential History, Assessment / Plan Vital Signs, and Testing and Results. The Title X FPAR 2.0 report is required under the Title X Service Grants and is generated by all family planning clinics receiving the Title X grants. The Office of Population Affairs (OPA) requires all Title X grantees to collect and submit FPAR data at the encounter level for the yearly reporting period, starting January 1 through December 31. The Title X FPAR report 2.0 must be set up and licensed for your practice. When the Title X 2.0 software is installed, the lab tests and the results also appear on the Title X 2.0 template. The LOINC® and SNOMED

Document Functional Status Assessment for Chronic Conditions

Recommendations

Document Functional and Cognitive Assessments

Document Patient's Mental Health Details Using the Brief Assessment Template

Document an Assessment

Document the Patient's Mental Health and Risk Assessment Information

Document Information about the Patient's Skill Assessment

Title X 2.0 Template Overview

Document Functional Status Assessment for Chronic Conditions

Document Functional and Cognitive Assessments

Document Patient's Mental Health Details Using the Brief Assessment Template

Document an Assessment

Document the Patient's Mental Health and Risk Assessment Information

Document Information about the Patient's Skill Assessment

Title X 2.0 Template Overview