Record Individuals Present

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Update the Client's Current Assessment

The Current Assessment panel provides quick entry of whether there has been a change or no change in the client’s condition. There are buttons to indicate the client’s progress or lack of progress. Navigate to the Current Assessment panel and select one of the statuses for Individual’s progress. Complete the Individual’s report of progress towards goals/objective since last session field. Enter No significant change or Notable change and if notable is selected, list the changes in individual’s condition field for the following: Mood/affect Thought process/orientation Motor activity and speech Behavior/functioning Medical condition Substance use/addictive behaviors If there has been any change in these areas, enter information about the change into the respective field or select Not applicable. To complete a full Substance Assessment, click on the Substance Use link to launch the BH Substance Use Assessment template. To document a comprehensive exam for the client’s current mental statu

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 Program Name

On the BH - Individual Counsel/Psych Prog Note template, expand the Program Name panel. Click the Program name field to select the appropriate name. To enter the Start time, do one of the following: Click the clock button to enter the current time in the field. In field, click to manually type the time. Previously entered times can be modified by clicking in the field. It is important to follow the established format: 0:00 AM or PM. Note: Program names can be added and/or edited on the Custom Picklists Setup system template. Parent topic: BH - Individual Counsel/Psych Prog Note Template

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 New Issues

Expand the New Issues panel. Under New issues/stressors/extraordinary events presented today, select from the available statuses. Enter relevant details in the Explanation field. Click the Task button to send an email to a coworker. Parent topic: BH - Contact Note Template Parent topic: BH - Individual Counsel/Psych Prog Note Template Parent topic: Group Visits for Behavioral Health Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)

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

Record Individuals Present

Recommendations

Update the Client's Current Assessment

Enter Goals, Objectives, and Interventions Addressed Today

Enter Program Name

Record a Risk Assessment

Record New Issues

Enter Assessment and Diagnosis Details

Update the Client's Current Assessment

Enter Goals, Objectives, and Interventions Addressed Today

Enter Program Name

Record a Risk Assessment

Record New Issues

Enter Assessment and Diagnosis Details