Document Physical Health Diagnoses and Psychosocial Stressors

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Add Psychosocial Stressors for the Client

The information gathered on the Bh Psychosocial Stressors template was previously included in the Axis IV section of the Assessment/Plan panel under the DSM IV standards. Information may be pre-populated when you enter the Bh Psychosocial Stressors template as the data carries forward from one encounter to the next unless the New Intake button has been selected at the beginning of the Comprehensive Assessment (Concerns tab, General panel). On the Bh Psychosocial Stressors template, select one of the descriptive status options. BH Psychosocial Stressors In the Problems related to section, select No or Yes and enter additional information in the corresponding field for the following areas: Primary support group Social environment Education Occupation Housing Finances Legal system/crime Accessing healthcare Other To enter additional information, click the Comments field. Click Save & Close. Parent topic: Enter Assessment and Diagnosis Details

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter Assessment and Diagnosis Details

Expand the Assessment/Diagnosis panel. If enabled, click the DSM IV link in the upper, right corner to launch the BH – DSM IV template. Note: The display of the link is set up on the Behavioral Health section of the Practice Configuration system template. In the Behavioral Health Diagnoses section, select any of the available links. In the Diagnostic description required field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. Add Status, Severity, Differential DX, and Impression.The out-of-the-box Severity picklist does not include Extreme or Persistent. These values can be added to the list in File Maintenance. Enter any required Specifiers by doing one of the following actions: Click the field to type a value. Click the My Phrases link to create a new sentence or part of a sentence. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User

NextGen Behavioral Health Suite Help 5.6

Document Psychosocial Stressors and GAF Score

From the Assessment/Diagnosis panel, select the Psychosocial Stressors link. The Tis Bh Psycho Stressors window opens. Select the severity. For Problems related to questions, select either No or Yes. If Yes, provide additional information in the text field. Optionally, use Comments to enter additional comments. In Current GAF, enter the score. To view the GAF scale, select the GAF Scale link. The date fills in with today’s date. If this is the first recorded GAF score, the Highest GAF in past year and Date fields fill in with according to the Current GAF information. To edit the date, select the date and then select a date from the calendar. Select Save & Close. To document a referral, select the Referral link. The Referral link opens the Referral Management template. The Referral Management template can be integrated with NextGen® Share to complete electronic outgoing referrals. For more information on entering referrals, go to NextGen Healthcare Success Community and download the Get

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Complete the Diagnoses Section for Transfer/Discharge

In the Behavioral Health Diagnoses section, select any of the available links: Diagnosis Code Lookup Add Common Assessment Mandated Care Coordination In the required Diagnostic description field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. In the Status field, click to select a value from the list. If appropriate, enter a Severity. If needed, enter a Differential dx, and/or Impression. To enter Specifiers, click one of the following: In the field to manually enter any required values 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. For chronic conditions, select the option to Mark diagnosis as chronic. Select the options to add the assessment to the Clinical problems, My tracked problems, and/or My favorites where applicable. Click Add To Grid. In the Physical Hea

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter DSM IV Assessment Details

In the Assessment/Diagnosis panel, click the DSM IV link to open the BH - DSM IV template. In the Axis I & II section, click the Copy Forward button to pull in previously entered assessment/diagnosis. Note: This button is enabled only if there is data available from a previous encounter. To open the Common assessment template, click Add Common Assessment. To document information for any person who should be contacted concerning this client, click Mandated Care Coordination. To enter a new diagnosis, click Add to open the Add or Update Assessment template. After a diagnosis has been entered, click Save & Close to return to the BH - DSM IV template. Do one of the following in the Axis III section: In the first available Diagnoses field, click to launch the diagnosis search window. Since the exact code for the client’s non-behavioral health diagnosis may not be apparent, you may not be able to select an Axis III diagnosis code. If available, select a code that was previously entered from

NextGen Behavioral Health Suite Help 5.6

Add Diagnostic Details

In the Assessment/Diagnosis panel, confirm the assessment selected displays in the Description details and ICD Code field. If not, select the assessment in the grid to fill in the details. Add Status, Severity, Differential Dx, and Impression. To enter specifiers in the Specifiers field, do one of the following: Select in the field and enter free text. Select the My Phrases link and select a phrase from the list. If applicable, select Present on Admission and then select a description from the list. To indicate the diagnosis is chronic, add the diagnosis to the client’s clinical problems list, and/or add the assessment to my tracked problems, select the respective checkbox. Select Add To Grid. The information displays in the grid. To add psychosocial stressors, select the Psychosocial Stressors link. To add referrals, select the Referrals link. To reorder the diagnoses, select Sort. To update a diagnosis, select the diagnosis in the grid, modify the details, and select Update. Parent t

Document Physical Health Diagnoses and Psychosocial Stressors

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