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Enter Goals, Objectives, and Interventions Addressed Today
In the
Goals/Objectives Addressed as Per Individualized Action Plan
section, click the
Goal today
field to select an item.
Select the
Objective today
from the list.
Click
Add
.
Select the appropriate
Stage of treatment.
In the
Therapeutic Interventions Delivered in Session
section, select any option that applies under
Describe interventions.
Enter information in the
Comment on all interventions selected
field.
Under
Counseling provided with client/family/caregiver
, select from the following topics:
Diagnostic results/impressions and/or recommended studies
Instruction for management/treatment and/or follow-up
Importance of compliance with chosen treatment
Client/family/caregiver education
Risks and benefits of treatment options
Prognosis
Risk factor reduction
Enter details for each selection in the
Comments
field.
Document the
Response to intervention/progress toward goals and objectives
.
Type details for each selection in the
Comments
field.
Under
Coordination of care provided
, set the
Coordination with
value and then enter a
Name,
and
Phone
information.
In the
Comments
field, manually type any additional information.
Enter Goals, Objectives, and Interventions Addressed Today
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
Enter the Prescriber's Evaluation
Expand the Prescriber's Evaluation panel. If there are no modifications, select the No changes reported/observed checkbox. In the Interim Update field, use the My Phrases link or manually type information about the client's progress since the last visit related to symptoms, effectiveness of medications, substance use, changes in family/social history, overall functioning, and any new issues. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. Parent topic: BH - Psychopharm Template
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record Plan Details
On the BH - Psychopharm template, navigate to the Plan panel. Document the Diagnosis since the last visit by selecting from the following: No change Yes, CA update required Next to Rationale for changing medications, select Not indicated or enter an explanation in the associated field. Answer No or Yes to: Were Medications delivered today. Next to If Yes, for what duration select one of the following options: Weekly Monthly Other Select No or Yes to indicate if there was a Prescription written. Document if the medication was Called into pharmacy. Next to Lab tests were ordered, select No or Yes. If Yes, enter available Results in the associated field Click the Review Labs link to open the Orders module and to view existing lab orders for this client. Document Instructions/comments/plan, as applicable. To schedule a follow up, click the Follow Up button to the right of Next Appointment. Follow-up/Disposition The Follow-up/Disposition template opens to document appointment details. Paren
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
Enter Goals, Objectives, and Interventions Addressed Today
Any goals and/or objective data that were previously entered on the Comprehensive Assessment template set populate in the panels found here. 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, field, click to Goal today select a previously entered item. Select an Objective today from the list of previously entered objectives. Click Add. In the Interventions Addressed Today section, do one or both of the following actions: Click Select From Previous IAP Intervention to select a previously entered value. Enter details in the Interventions/methods provided memo field. Click the My Phrases link to select a sentence to enter in the Interventions addressed today section. Click Add. Click Save & Close. Enter the Response to Interventions/progress toward goals and objectives. Parent topic: BH - Individual Counsel/Psych Prog Note Template Parent topic: Group Visits for Behavioral He
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
