Loading...
Recommendations
Explore
Document Individuals Present
In the
Individuals Present
panel, select from one of the
Contact type
values.
In the
Individuals Present
section, do on of the following:
Select
Individual not present
and a
Reason
.
Select
Individual present.
Select
Others present
and document their names.
Enter the client's closest friends and relatives in the
Support Resources
section and click
Add
.
Note:
The
First name
and the
Effective
date are required
To set the filter, click
Active
to view just the current resources or click
All
to see every resource ever associated with this client.
Document Individuals Present
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Treatment Recommendations/Assessed Needs
On the Treatment Recommendations/Assessed Needs panel, if appropriate, select No additional recommendations clinically indicated. To create a new entry, click the Priority field to enter a number. Type an Assessed Need. In the Status field, click to select a value from the Need status list. Enter a date in the Identified field. If applicable, enter Rationale(s) and/or a Resolved date. Click Add. Repeat steps 1 - 6 as needed. In the Further Evaluations Needed section, do one of the following: Select None indicated. Place a check mark next to any of the applicable options. Enter details in the Level of care/indicated service recommendations field. Type a summary in the Individual served/guardian/family response to recommendations field. In the Treatment Planning Updates section, select No or Yes to Change in IAP Required. If Yes is selected, complete the IAP revision by clicking IAP Review at the top of the template. Parent topic: BH - Psychiatric Evaluation
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter Document Signatures
Multiple people may be required to sign the encounter. Security on the Signatures panel is set up so that only the person who checks a signature line can alter it in any way. The name of the user who is logged on to the computer fills in the name field, along with the date of the signature. After ‘signing’, you can send a task to the next person who has to sign off. Electronic signature software can be used to capture the signature for the client or parent/guardian. In the Signatures panel, place a check mark next to the label(s) that apply. If needed, enter or modify any Credentials to further identify a signature. To indicate that signature is not applicable and clear the fields of anything that may have been entered in the same row select N/A. Click the Send Task button to forward the template to the next person in line to sign off. If your signature does not fall under the preset options, use the Additional Staff section. Name and Date are required fields. Enter any additional Comm
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter Psychiatric Evaluation Presenting Concerns
The Presenting Concerns panel enables you to document the symptoms and presenting issues, in the client's own words, which prompted a visit to the office in the Reason for referral field. In the Presenting Concerns panel select No or Yes to answer the question: Comprehensive Assessment has been completed. If Yes, enter the date of the most recent assessment into the field. In the Reason for referral and chief complaint field, click to enter or dictate notable symptoms, presenting problems, behavioral and functional needs, etc. Enter Family/guardian description of problem. For History of present psychiatric illness, do one of the following actions: Select None reported. Enter or dictate history details. Parent topic: BH - Psychiatric Evaluation
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Mental Health and Addiction Treatment Service Histories
On the Mental Health and Addiction Treatment Service History panel, do one of the following: Place a check mark for None reported. In the Treatment services history within the past five years section, enter as much information acquired from the client in the fields. Type of service is the only required field in this section. Click Add. In the Outpatient section, select Not applicable or enter the Age at time of initially seeking outpatient treatment services. Enter the Total number of lifetime outpatient treatment experiences. In the Inpatient section, select Not applicable or enter the Age at time of initial inpatient treatment. Click the Total number of lifetime inpatient treatment experiences field to enter a value. In the Er/detox section, select Not applicable or enter the Total number of er visits in the last 6 months. Enter the Number of non detox hospital days in the past 6 months and select a reason. Medical Psychiatric Both Click the Number of days the client has been in drug
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Individuals Present
In the Individuals Present panel, select from one of the Contact Type options. Select one of the following in the Individuals present section: Individual not present Individual present Select Others present and enter the details in the Support Resources section. In the Support Resources section, record the client's closest friends and relatives. To add the support resources data in the grid, click Add. To change the grid view, select All or Active. The Effective and End dates determine if a resource is Active. Parent topic: BH - Contact Note Template Parent topic: BH - Psychopharm Template Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record Individuals Present
Open the BH - Individual Counsel/Psych Prog Note template. In the Individuals Present panel, select from one of the options for the Modality. Modality is only available on the Progress Note tab. In the Individuals Present section, select one of the following set of values: Individual not present and a Reason Individual present and a Contact Type If applicable, place a check mark next to Others present and type in the person's name and/or relationship in the field when it becomes available. The Support Resources section is where information about the client's closest friends and relatives are recorded. To enter a new person under Support Resources, fill in the fields in this section (First name and the Effective date are required) and click the Add button. The Effective and End dates determine if a resource is Active. To set the grid view, select one of the resource filters: Active All Parent topic: BH - Individual Counsel/Psych Prog Note Template
