Sign the Behavioral Health Document

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

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 Vital Signs for the Nurse Progress Note

On the Vital Signs panel, click Historical information entered this encounter to view all vitals for the current encounter. Click History to view a complete history of the client's vitals. Click Add to add a new set of vitals. The Vital Signs (Lite) - [New Record] template appears. The Measured date, Time, and Measured by fields are populated. However, the date and time can be manually changed but the user name in the Measured by field cannot be modified. Enter information using the on-screen numeric keypad. Click the NEXT button below the numeric keypad to enter information in the next field. Select the Carried forward option to pull a previously entered Height into this field. After a Height and Weight value are entered, a BMI value is calculated below the numeric keypad. Select the BMI Plan link to open the Health Promotion Plan template, where an out-of-range BMI can be easily addressed with diet, exercise, and referral information. The Functional Status panel on this template prov

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Finalize Billing for Nurse Notes

The Start and End time clock buttons are available in the Behavioral health billing section and on the Program Name panel above. The values documented in either place are immediately reflected in the same fields on the other section. Entered times can be modified by clicking in the field. If desired, you can document the time values at a later date. It is important to follow the established format: 00:00 AM or PM. To finalize billing on the Nursing Note (Long) or the Nursing Note (Short) template, navigate to the Behavioral health billing section. To enter the End time, click one of the following: Click the clock to enter the current time. In the field to type the time that marked the end of the exam. The read-only Duration field automatically fills after the End time is entered. If appropriate, select the option for Service performed by. The system fills the fields with the name of the current user. A stored procedure that works with the Service Code Mapping practice template calculat

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Record Signatures on the Group Therapy Progress Note

Multiple people may be required to sign a treatment plan. 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 name of the user who is logged on to the computer populates in the name field, along with the date of the signature. After ‘signing,’ the signer clicks on the Send Task button in the upper right of this panel. The template is sent to the next person who has to sign off. Electronic signature software can be used to capture the signature for client and/or parent/guardian. To record signatures in the Signatures panel, place a check mark next to the applicable label(s). Enter any Credentials to further identify a signature. Select N/A to indicate that a signature is not applicable and clear the fields of anything that may have been entered in the same row. The Send Task button facilitates forwarding the template to the next person in line to sign. If one of the required signatures does not fall under the preset

Sign the Behavioral Health Document

Recommendations

Record New Issues

Enter Assessment and Diagnosis Details

Update the Client's Current Assessment

Record Vital Signs for the Nurse Progress Note

Finalize Billing for Nurse Notes

Record Signatures on the Group Therapy Progress Note

Sign the Behavioral Health Document

Record New Issues

Enter Assessment and Diagnosis Details

Update the Client's Current Assessment

Record Vital Signs for the Nurse Progress Note

Finalize Billing for Nurse Notes

Record Signatures on the Group Therapy Progress Note