Start a New Intake

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Intake Process for Comprehensive Assessment

The intake process is designed to be completed over several visits if needed. The Comprehensive Assessment templates can be accessed on a future encounter to finish the intake. If this documentation represents a new problem or the recurrence of an old problem, the New Intake button is used. When selected, a confirmation window states that you are about to clear data. Selecting Yes indicates that you are beginning a new episode of care. The historical data still exists in the past encounters. Start a New Intake Record the Client's Presenting Concerns Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Start a New Intake for a Brief Assessment

The General Panel enables you to document a new episode of care, if applicable. The Start and End buttons are available here and on the Behavioral health billing section at the bottom of the template. The values documented in either place are immediately reflected in the same field on the other section. The times can be modified by clicking in the field. If desired, you can enter a time at a later date. It is important to follow the established format: 0:00 AM or PM. In a Behavioral Health visit, expand the navigation bar and at the top of the third grouping of available links, click Brief Assess. Select the Discussed confidentiality and obtained consent for care option. When this option is not selected, the text appears in a bold font and no references to confidentiality print on the document. After selection, the text turns to back to a regular font (not bold) and a line item at the top of the document reads: Confidentiality discussed and consent for care obtained. To start a new int

NextGen Behavioral Health Suite Help 5.6

Document the Initial Screening Details

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Screening Note (BH), and then select OK. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Individuals Present panel, document the details of the individuals present during the assessment. Enter your plan and discussion on the patient's treatment. Note: You can select Copy Forward to copy existing details from another encounter to the current encounter. Document the patient's assessment and diagnosis details. Document the applicable signatures from the tasking supervisor or staff. In

NextGen Behavioral Health Suite Help 5.6

Document the Patient's Case Management Services in the Contact Note

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Contact Note (BH), and then select OK. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Goals, Objectives, and Interventions Addressed Today panel, document the patient's goals, objectives, and interventions addressed on the current date. Enter your plan and discussion regarding the patient's treatment. Note: You can select Copy Forward to copy existing details from another encou

NextGen Behavioral Health Suite Help 5.6

Document the Assessment and Billing Information

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Assessment/Reassessment Billing (BH), and then select OK. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Treatment Recommendations/Assessed Needs panel, document the recommended treatments and the patient's needs. Document the patient's assessment and diagnosis details. Document the applicable signatures from the tasking supervisor or staff. In the Time Entry Navigation sidebar

NextGen Behavioral Health Suite Help 5.6

Document the Patient's Comprehensive Clinical and Nursing Details

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Nursing Note (BH), and then select OK. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Vital Signs panel, select Add to capture the patient's vitals. In the New Issues panel, document the patient's new issues and the status. In the Risk Assessment panel, document the patient's risks towards suicide or danger to self or properties. Document whether the patient takes medication as prescribed. Document the patient's alleries and their current status. Enter your plan and discussion on the patient's treatment. Note: You can select Copy Forward to copy existing details from another encounte