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Record Mental Status Exam Information
Record Mental Status Exam Information
To record information on the
Mental Status Exam
panel, record a response to the question
Does the individual require a full Mental Status Exam?
Select
Yes
for a comprehensive record and click the
Mental Status Exam
link.
Select the
No
if a full status exam is not necessary.
Note:
It is up to the provider to determine if a full mental status exam is required.
Indicate whether there has been
No significant change
or
No notable change
in the following areas and type any notable change in the adjacent fields:
Mood/affect
Thought process/orientation
Motor activity and speech
Behavior/functioning
Medical condition
Substance use/addictive behavior
Select the
Not applicable
checkbox if substance use or addictive behaviors do not apply to this client.
Click the
Substance Use
link to open the
BH Substance Use Assessment
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
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
Record Mental Status Exam Information
For a more comprehensive record than is offered on the Mental Status Evaluation panel, click the Mental Status Exam link. The BH - Mental Status Exam template opens. Note: The determination to perform a full exam should be made by the provider. Alternatively or in addition, a mental status narrative, including the client's appearance, mood, affect, speech, thought process/content, cognition, and insight/judgement can be entered in the Written narrative field. Parent topic: BH - Brief Assessment Template
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Complete the Mental Status Exam Template
The BH - Mental Status Exam template is part of the assessment process (Comprehensive Assessment and Psychiatric Evaluation). The provider’s observations of behavior and assessments of mental health symptoms can be documented here. The Mental Status exam can be completed at every visit and do not copy forward onto future encounters. In the Mental Status Evaluation panel, click the Mental Status Exam link. The BH - Mental Status Exam template appears. The General Observations panel includes the option to select Generally normal for all of the areas presented. You can select this option and still choose specific items under each area to indicate traits observed for this client. If appropriate, select one or more options for each area within the panel. To chart by exception on the remaining panels, select the Unremarkable option to populate the first checkbox for each section (except Hallucinations, on which both Denied and None evidenced are selected). Choose another option in any of the
NextGen Behavioral Health Suite Help 5.6
Complete the Mental Status Exam Template
The BH - Mental Status Exam template is part of the assessment process (Comprehensive Assessment and Psychiatric Evaluation). The provider’s observations of behavior and assessments of mental health symptoms can be documented here. The Mental Status exam can be completed at every visit and do not copy forward onto future encounters. In the Mental Status Evaluation panel, select the Mental Status Exam link. The BH - Mental Status Exam template appears. The General Observations panel includes the option to select Generally normal for all of the areas presented. You can select this option and still choose specific items under each area to indicate traits observed for this client. If appropriate, select one or more options for each area within the panel. To chart by exception on the remaining panels, select the Unremarkable option to populate the first checkbox for each section (except Hallucinations, on which both Denied and None evidenced are selected). Choose another option in any of th
