Enter Goals, Objectives, and Interventions Addressed Today

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® Adaptive Content Engine Help Enterprise 8.3.1

Record a Risk Assessment

Any assessment of risk data that was entered previously on the Comprehensive Assessment template set carries forward to the panels found here. On the Risk Assessment panel, if the patient is not a danger to self or other, select the option for Patient is not currently a danger to self, others, or property. Selecting this option sets every field in the section as unavailable. The Encounter field fills with the current date. In the Risk field, select the appropriate type of risk from the list. If there is a need to record a previous risk for the client, select the Past option. CAUTION: Always document past risks before a current assessment. If Past is selected, either an Event Date (even if approximate) or Denied should be populated. If there are no past assessments to document, select the option for Current. Select Denied or Admits. If Denied is selected, the documentation options are all disabled in this section except for the date fields and the Add and Clear buttons. Enter the Event

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

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Complete Behavioral Health Billing

For a group encounter, billing can be applied at the individual or group level. Data entered or modified in the group section appears for every member and cannot be modified at the individual level. The Start and End time buttons are available in both of these sections and on the Program Name panel for a group note. The values documented in either place are immediately reflected in the same fields on the other section. Entered times can be modified by clicking in the field. If desired, you can document the time values at a later date. It is important to follow the established format: 00:00 AM or PM. Navigate to the Signatures panel on the BH – Group Therapy Progress Note template. Do one of the following actions in either the Group or Individual section: Click the clock to enter the current value in the End time field. In the field, click to type the time that marks the end of the exam. The read-only Duration field fills with the calculated duration value after the entry of the End tim

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter Goals, Objectives and Interventions Addressed Today

Goals and/or objectives that were entered previously on the Comprehensive Assessment templates populate in this panel. The grid on this panel offers a quick view of the client's current goals and objectives. In the Goals/Objectives Addressed As Per Individualized Action Plan section, Goal today field, click to select a previously entered item. Select the Objective today from the list previously entered objectives. Click Add. In the Interventions Addressed Today section, click Select From Previous IAP Intervention to choose a previous entered value. Enter the Interventions/methods provided. Record the Response to Interventions/progress toward goals and objectives. Document the Issues referred to physician/psychiatrist for consideration. Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter Goals/Objectives and Interventions Addressed Today

Expand the Goals/Objectives and Interventions Addressed Today panel. Click the Goal today field to select a goal from a list of previously entered goals. A goal must be entered before an objective can be selected. Select the Objective today from the list. Click the Add button. In the Interventions Addressed Today section, do one or both of the following: Click the Select From Previous IAP Interventions link to choose a value previously entered for the client. Click Select Other Interventions to open a practice-wide list of interventions. Each selected intervention appears in the Intervention/method provided field. Add additional details by typing in the Intervention/method provided field. Enter the Response to Interventions/progress toward goals and objectives. Parent topic: BH - Contact Note Template

Enter Goals, Objectives, and Interventions Addressed Today

Recommendations

Enter Assessment and Diagnosis Details

Record a Risk Assessment

Record Individuals Present

Complete Behavioral Health Billing

Enter Goals, Objectives and Interventions Addressed Today

Enter Goals/Objectives and Interventions Addressed Today

Enter Goals, Objectives, and Interventions Addressed Today

Enter Assessment and Diagnosis Details

Record a Risk Assessment

Record Individuals Present

Complete Behavioral Health Billing

Enter Goals, Objectives and Interventions Addressed Today

Enter Goals/Objectives and Interventions Addressed Today