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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
.
The
Follow-up/Disposition
template opens to document appointment details.
Record Plan Details
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
Document Individuals Present
In the Individuals Present panel, select from one of the Contact Type options. Select one of the following in the Individuals present section: Individual not present Individual present Select Others present and enter the details in the Support Resources section. In the Support Resources section, record the client's closest friends and relatives. To add the support resources data in the grid, click Add. To change the grid view, select All or Active. The Effective and End dates determine if a resource is Active. Parent topic: BH - Contact Note Template Parent topic: BH - Psychopharm Template Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)
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 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
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Access the BH - Psychopharm Template
To access the BH - Psychopharm template, set the Specialty to Behavioral Health and then select one of the following for the Visit Type: Medication Management with Psychotherapy Medication Management with Psychotherapy & Translator Click the Psychopharm F/U tab. The BH - Psychopharm template opens. Optionally, click the Psychopharm Note link from the left navigation bar. Parent topic: BH - Psychopharm Template
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Medication Information
On the BH - Psychopharm template, expand the Medication Information panel. Answer the following questions with Yes, No, or Not applicable as applies: Takes meds as prescribed Changes in medical status Other meds Allergic reactions Side effects reported Note: All allergic reactions must be entered in the Allergies module to ensure that they are apparent on future visits. Click the Side effects reported link to open the Medication Side Effects - BH template. Entering information on the template automatically selects the Yes option in the Medication Information panel and turns the Side effects reported link purple to indicate that data is present from that link. At the top of the grid, click the Comments link if additional information is required. All prescriptions currently existing in the Medications module are visible in the grid under the Active Medications section. If a medication is Inactive, a stop date appears in the grid. Under Active Medications, double click in the grid to laun
