Document Issues for Children/Adolescents
Expand the
Issues for Children/Adolescents
panel.
Record the answers to the following issues for children/adolescents:
Wish list
Worry list
Ambitions
What makes you happy
What makes you sad
To whom do you go to when you are sad or worried
Other
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Document Issues for Children/Adolescents
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
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. Parent topic: BH - Psychiatric Evaluation
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
Enter Developmental History Information
All of the data in the Development History panel carry forward data from encounter to encounter for ease of documentation. Navigate to the Development History panel. Select from one of the links at the top of the panel: Developmental Milestones - document Child Developmental Record (data shares from the Pediatrics template set) and/or Child Development History (information can be free-typed). M-CHAT and PSC developmental screenings (described below) can also be recorded on the Child Development Record template Modified Checklist for Autism in Toddlers (M-CHAT) - enter data and calculate a score (same template that is available from the Developmental Milestones link) Robins, D.L., Fein, D., & Barton, M. (2009). The Modified Checklist for Autism in Toddlers, Revised, with Follow-up (M-CHAT-R/F). Self-published. Pediatric Symptom Checklist (PSC) to enter data and calculate a score (same template available from the Developmental Milestones link) Bright Futures Resource and Tool Kit ©2010 -
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Add Sexual Issues
The data in the fields on the Sexual Issues panel carries forward from encounter to encounter. In the Sexual Preference field, click to select a value from the list. Enter the client's sexual orientation and other relevant information in the Sexual history/concerns field. If additional details are required, click the Sexual Practices/STI's link to document on the Confidential - Sexual Practices/STIs template. Parent topic: BH - Psychiatric Evaluation
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record New Issues
Expand the New Issues panel. Under New issues/stressors/extraordinary events presented today, select from the available statuses. Enter relevant details in the Explanation field. Click the Task button to send an email to a coworker. Parent topic: BH - Contact Note Template Parent topic: BH - Individual Counsel/Psych Prog Note Template Parent topic: Group Visits for Behavioral Health Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)
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
