Record Vital Signs for the Nurse Progress Note

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

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

Sign the Behavioral Health Document

Multiple people can sign the Behavioral Health document utilizing the Signature panel. Security on the Signatures panel is set up so that only the person who checks a signature line can alter it in any way. The client and/or parent/guardian’s signatures can be captured with electronic signature software. To document your signature in the Signatures panel, place a check mark next to the appropriate label. The current user’s name fills the Name field and the current date populates the date of the signature. Enter your Credentials. Select N/A to indicate that a signature is not applicable and to clear the fields of anything that may have been entered in the same row. Click the Send Task button to forward the template to the next person who needs to record their signature. If your signature does not fall under the preset options, enter your Name and Credentials in the Additional Staff section. Enter Comments as needed. Click Add. The signature details appear in the grid. Parent topic: BH -

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Medication Information

On the BH - Nursing Note template, navigate to the Medication Information panel and answer the following questions with No, Yes, or N/A (Not Applicable) and enter Comments as needed: Takes medications as prescribed Changes in medical status Reviewed medication name(s), dosage, purpose, and frequency Were medications delivered today - If yes, for what duration 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 a template on which medication side effects can be documented. Next to Other medications, select from the following options: None Herbal Over the counter Other - and type specifics in the associated field Click the Office Procedures link to launch the My Plan tabbed template set on the Office Procedures tab and document medications administered today. Click Comments to record a medication comment. Do one of the following actions

NextGen® Ophthalmic Suite Help 2022.2

Document Vital Signs

You can document vital signs for the patient on the Vital Signs Lite template. Note: To document numeric values for height, weight, temperature, pulse, and respiration quickly, enter the values using the number pad. Click Next to move to the next field. Click Add below the Vital Signs grid. The Vital Signs Lite template opens. To document unobtainable vital signs, select one of the following check boxes, and then select the vital signs that were not obtained from the list. Unobtainable Patient Refused By default, the Measured date and Time fields display the current system date and time. Click the Time field to select a value to enter vitals measured at an earlier time.By default, the current user information appears in the Measured by field and cannot be changed. To enter Height, do the following: Record the height in the ft and in fields or in the cm field. The Last measured field displays the current system date when you enter height information. The value for height is carried forw

Record Vital Signs for the Nurse Progress Note

Recommendations

Document Individuals Present

Enter Assessment and Diagnosis Details

Record a Risk Assessment

Sign the Behavioral Health Document

Document Medication Information

Document Vital Signs

Record Vital Signs for the Nurse Progress Note

Document Individuals Present

Enter Assessment and Diagnosis Details

Record a Risk Assessment

Sign the Behavioral Health Document

Document Medication Information

Document Vital Signs