Social Hx of a Comprehensive Assessment

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

BH - Psychiatric Evaluation

The Psychiatry Eval tab is designed to be a stand-alone template for a psychiatrist, nurse practitioner (NPP), or other Behavioral Health professional who is qualified to conduct and document an initial psychiatric assessment of the client. The information on the Psychiatry Eval tab overlaps with the data recorded on the Comp Assess tab. Of the 17 panels on the tab, only two (Physical Health History and Issues for Children/Adolescents) are not identical to the corresponding panels on the Comprehensive Assessment. If a Comprehensive Assessment was completed for this client prior to the Psychiatric Evaluation, much of the information is filled. It is important to note that medications can be prescribed during the psychiatric evaluation. The Behavioral health billing section is available at the bottom of the Psychiatry Eval and Progress Note tabs to submit billing codes. Some providers may want to use the SOAP tab to document additional elements of the physical exam. For more information

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

BH Hx Section Tab Overview

The Behavioral Health History (Bh Hx) section tab enables you to document the client's mental health history, substance use, risk assessment and to complete various screening tools. From this tab, users have access to the Past Medical History, Substance Use Assessment Exam, Social History - Tobacco, and Mental Status Exam templates. Enter Psychiatric Illness History Data Record Substance Use and Addictive Behavior Histories Substance Use Assessment Exam Document Mental Health and Addiction Treatment Service Histories Medication Information Panel Mental Status Evaluation Panel Record a Risk Assessment Enter Risk and Alert Histories Complete Behavioral Health Screenings on the Screening Tools Panel Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Access the BH CA Presenting Concerns Template

To complete a comprehensive assessment as part of the intake process, enter the following information on the Home Page - Behavioral Health template: In the Visit Type field, select a value from the list. Select Intake no Medical Services or any of the other Visit Types listed in the above section of this User Guide. Click the Comp Assess tab to launch the BH CA Presenting Concerns template. The Concerns section tab is highlighted to indicate that you are on the w template. The abbreviations presented in the name of the template refer to Behavioral Health (BH) and Comprehensive Assessment (CA). Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Client's Living Situation

The Living Situation panel on the BH CA Social History template enables you to document specific details about the client's housing situation. Open the BH CA Social History template and expand the Living Situation panel. Record Where is the individual currently living. Note: The list for living situation may be edited by the practice. Enter the Residential care/treatment facility details. Indicate if the client is At risk of losing current housing and enter additional Comments. Answer No or Yes to the question: Satisfied with current living situation. Click Add next to the Residence field to enter who is living with the client. To enter additional information related to the living situation, click Comments.Notice the character counter at the bottom of the Comments field. This lets the user know how many of the 500 available characters are left to ensure that all of the information prints on the generated document. These character counters are available on memo fields throughout the Beh

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document Sexual Issues

The field data on the Sexual Issues panel carries forward from encounter to encounter. Open the BH CA Social History template and expand the Sexual Issues panel. Enter the client's Sexual Preference. Free text or dictate notes about the client's sexual orientation and other relevant information in the Sexual history/concerns field. Parent topic: Social Hx of a Comprehensive Assessment

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Patient's Employment Status

You can document the patient's employment status for Behavioral Health by using the BH CA Social History template. Open NextGen® Enterprise EHR. Open the Intake template, and then select the Behavioral Health specialty and Onsite Consult visit type. In the navigation bar, select the History - BH link.The BH CA Social History template opens. Expand the Employment Status panel. In Current employment status, enter the average number of hours worked per week. Optional: If not currently employed, enter the reason. If the employment belongs to Other, then enter the details. Select No, Yes, or Uncertain as applicable. In Comments, enter any additional information about the client's work status. In Employment History, select Add or Edit, enter the employment details, and then select Close. Parent topic: Social Hx of a Comprehensive Assessment

Social Hx of a Comprehensive Assessment

Recommendations

BH - Psychiatric Evaluation

BH Hx Section Tab Overview

Access the BH CA Presenting Concerns Template

Document the Client's Living Situation

Document Sexual Issues

Document the Patient's Employment Status

Social Hx of a Comprehensive Assessment

BH - Psychiatric Evaluation

BH Hx Section Tab Overview

Access the BH CA Presenting Concerns Template

Document the Client's Living Situation

Document Sexual Issues

Document the Patient's Employment Status