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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 and/or alcohol inpatient detox in past 6 months
field to enter a value.
Enter additional details in the following fields:
What was helpful with past treatment
What was not helpful
Additional comments
Document Mental Health and Addiction Treatment Service Histories
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record Substance Use and Addictive Behavior Histories
On the Substance Use/Addictive Behavior History panel, select the None reported checkbox if the client denies substance use or addictive behavior. Select one or more of the addictions options reported by the client. Use the Other field can be selected to type an historical issue that is not available on the panel in the associated field. Select the client's response for Drinks alcohol. Click the Tobacco Usage link to enter the client's tobacco use. If any of the addiction options apply and a more in-depth evaluation is required, click the Substance Use link to enter more details. The BH Substance Use Assessment template launches. Enter Tobacco Usage Parent topic: BH Hx Section Tab Overview See also Substance Use Assessment Exam
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record Substance Use and Addictive Behavior Histories
On the Substance Use/Addictive Behavior History panel, select the None reported checkbox if the client denies substance use or addictive behavior. Select one or more of the addictions options reported by the client. If needed, Other can be selected to type an historical issue that is not available on the panel in the associated field. Select the client's response for Drinks alcohol. If no information has been entered for the client's tobacco use history elsewhere, the read-only field is blank; to enter this data, click the Tobacco Usage link. If any of the addiction options apply, click the Substance Use link available at the top, right of the panel to gather more details.The BH Substance Use Assessment template opens. Enter Tobacco Usage Parent topic: BH - Brief Assessment Template Parent topic: BH - Psychiatric Evaluation
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
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
BH Hx Section Tab Overview
The Behavioral Health History (Bh Hx) section tab enables you to document the client's mental health history, substance use, risk assessment and to complete various screening tools. From this tab, users have access to the Past Medical History, Substance Use Assessment Exam, Social History - Tobacco, and Mental Status Exam templates. Enter Psychiatric Illness History Data Record Substance Use and Addictive Behavior Histories Substance Use Assessment Exam Document Mental Health and Addiction Treatment Service Histories Medication Information Panel Mental Status Evaluation Panel Record a Risk Assessment Enter Risk and Alert Histories Complete Behavioral Health Screenings on the Screening Tools Panel Parent topic: Comprehensive Assessment Template Set
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Alcohol or Drug Use History
On the Confidential - Alcohol/Drug template, go to the Alcohol Use section. Enter the age on the Age Alcohol Use Began numeric keypad in the Age Started field. Select the No or Yes option for the following queries: Sought treatment for alcohol abuse Involved in a 12-step program Have you had withdrawal problems, seizures or blackouts from alcohol or drugs Emergency medical attention required due to intoxication Family Hx of alcoholism To document treatment, enter the date of the last drug treatment, and the number of times the patient received drug treatment. Under Drug Use/Abuse, select an option to indicate if the patient uses drugs. If the selected option is No, no other documentation is required in this section. If the selected option is Yes or Formerly, document the age at which patient started using drugs, drug type, frequency of drug use and route. Select the Quit checkbox to indicate that the patient used the associated drug formerly and has quit. Select either Yes or No for th
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
