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Document Known Substance Use for Transfer/Discharge Summary
Document Known Substance Use for Transfer/Discharge Summary
In the
Substance Use
section on the
BH – Transfer/Discharge 2
template, select from one of the following options:
Alcohol
Benzodiazepines
Cocaine
Opioids
Nicotine
Other
To continue documenting in the template set, do one of the following actions:
Click the
Previous
button.
Click
Next
.
Select the
Assessment Section
tab.
Select the
Plan Section
tab.
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter a Discharge Summary and Treatment
On the BH - Transfer/Discharge 2 (the Summary section tab in the Transfer / Discharge template set), describe the type of treatment received and how often in the Modality/frequency field. Type a specific Duration in the associated field. Describe the client's Compliance. In the Focus of Treatment field, click one of the following: The Focus of Treatment field to enter a brief description. The My Phrases link For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. Answer the question Were treatment goals achieved and provide a brief history. Parent topic: Enter Transfer/Discharge Data
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter Transfer/Discharge Data
The assessment and diagnosis information of the client being transferred or discharged can be entered on the BH - Transfer/Discharge 1 template. Select the Transfer or Discharge option. Enter a Date. Select from one of the available statuses or choose Other to type an explanation of the client's situation. If enabled, click the DSM IV link that appears in the upper, right corner to launch the BH – DSM IV template. The display of the link is setup on the Behavioral Health section of the Practice Configuration system template. Complete the Diagnoses Section for Transfer/Discharge Enter a Discharge Summary and Treatment Enter Post Discharge Support Systems for the Client Record the Client's Discharge Risk Assessment Document Known Substance Use for Transfer/Discharge Summary Parent topic: Transfer or Discharge Visit Workflow
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Transfer or Discharge Visit Workflow
Set the Visit Type to Discharge Planning on the Home Page - Behavioral Health template to access the Transfer/Discharge tab, which includes three section tabs. The BH - Transfer/Discharge template set can also be accessed at any time by clicking Discharge/Transfer on the bottom section of the left navigation bar. Navigation Bar The BH - Transfer/Discharge template set includes three section tabs: Assessment Summary Plan Enter Transfer/Discharge Data Complete the Transfer/Discharge Plan Parent topic: Behavioral Health
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Tobacco Use on the Substance Use Assessment Exam
On the BH Substance Use Assessment Exam template, expand the Tobacco Use panel. Previously entered data fills the field next to: Has the individual ever used tobacco (nicotine). If required, click the Tobacco Usage link to add or modify this information. Enter the Age of first use. Click the field for Frequency of use to select an item from the list. Set the Date of last use. Select Smoking or Chewing for the Primary route of administration. Parent topic: Substance Use Assessment Exam
NextGen Behavioral Health Suite Help 5.6
Discharge Summary
Your practice can configure the templates to be accessed from your Packet Navigation or you can access the template from the Templates module Template Icon. For more information, go to NextGen Healthcare Success Community and download the Configuration Guide for NextGen® Behavioral Health Suite. Document Discharge Summary Use the Discharge Summary (BH) template to close and discharge the client from outpatient program services. Assessment and Diagnosis Functionality You can enter assessment information for the current encounter by using the Assessment/Diagnosis panel. Task Supervisor/Staff for Review and Signoff The table provides information about the tasks related to the Signature (Tasking Supervisor/Staff for review and signoff) panel. Parent topic: Using NextGen Behavioral Health Suite
NextGen Behavioral Health Suite Help 5.6
Document the Patient's Transfer Summary
You can document the patient's transfer details from one program to another. 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 Transfer Summary (BH), and then select OK. Select the program, specialty, and visit type. Select the patient's discharge date. To close the selected program for the patient, select the status of the patient's treatment in the program. In the Assessment/Diagnosis panel, document the patient's active diagnosis and assessment details. In the Transfer Summary panel, document the treatment details, post-transfer support details, risk details, and the reason for the patient's transfer. In the Transfer Plan panel, document the patient's active medications and transfer plans and instructions. Select Generate Document. Assessment and Diagnosis Functionality You can enter assessment information for the current encounter by using the Assessment/Diagnosis panel.
