Add or Update Assessment Template

NextGen® Adaptive Content Engine Help Enterprise 8

Behavioral Health Common Assessment Page

The BH Assessment page that opens in the Add Common Assessment template includes the following updates for DSM-5: When the Practice Configuration practice template option to display a link for the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM IV) is not selected, the Add Common Assessment template for Behavioral Health displays an updated grid and picklist (replacing the required, DSM IV, Axes lists). The Status picklist is not required. Users can cancel out of the list without making a selection. The picklist includes the following selections: Mild Moderate Severe Persistent Extreme The grid in the DSM-5 section includes the following headers: # Dx (Code) Status Severity Impression/Differential Dx Specifier The system is packaged with existing, common assessment, diagnosis code data formatted to appear on the Common Assessment template. If no data is preloaded for a common assessment set in the package, launching that common assessment page returns the foll

NextGen® Adaptive Content Engine Help Enterprise 8

Access the Add or Update Assessment Template Based on DSM-5 Standards

The Behavioral Health version of the Add or Update Assessment template is based on DSM-5 standards. On the Home Page - Behavioral Health template, set the Visit Type to Onsite Consult. On the SOAP tab, expand the Assessment/Plan panel and click the Add Assessment button. The Behavioral Health version of the Add or Update Assessment template displays. Parent topic: Add or Update Assessment Template

NextGen® Adaptive Content Engine Help Enterprise 8

DSM-5 Overview

The Diagnostic and Statistical Manual of Mental Disorders (DSM) manual is the primary source used by clinicians to diagnose and classify mental disorders. The date of implementation for the Fifth Edition (DSM-5) coincided with the go-live date for the International Classification of Diseases and Related Health Problems 10th Revision (ICD-10), which is also required for reporting and claim submissions. DSM-5 is needed to assign Health Insurance Portability and Accountability Act (HIPAA) compliance and valid diagnosis code Clinical Modifications (ICD-10-CM) to a psychiatric diagnosis. The Behavioral Health template set in NextGen® Adaptive Content Engine includes revised functionality to enable the documentation of assessments using the standards in the latest manual. The Assessment/Diagnosis panel, which has always been specific to Behavioral Health, is updated to reflect the DSM-5 standards. The Global Assessment of Functioning (GAF) data is available on the Assessment/Diagnosis panel

NextGen® Adaptive Content Engine Help Enterprise 8

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 latest Getting Start

NextGen® Adaptive Content Engine Help Enterprise 8

Using the Assessments Tab

The Assessments tab in the My Plan template set houses the Add or Update Assessment template. The grids on the Assessments tab can be filtered. For example, in the Billing Diagnosis History section, selecting the Show Chronic only check box displays only those diagnoses that are not acute. Selecting the option to Add Assessments on 1 click speeds up the documentation process by including the diagnosis description and code for Today's Assessment in the grid and Problems module without having to click Add/Update. The Medications or Immunizations links can be used at any time during the encounter to access the associated module. Open the Assessments Tab Document an Assessment You can document an assessment on the Add or Update Assessment template. Shared Working Assessment The group of templates that share the selected assessment for the patient. Change the Order of Assessments in the Grid Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the To

NextGen® Adaptive Content Engine Help Enterprise 8

Grids in Add or Update Assessment Template

The Add or Update Assessment template includes the following grids. Grid Description Today’s Concerns/Reasons for Visit Displays the concern or reason of visit. Billing Diagnosis History Displays a list of active diagnoses for this particular patient Clinical Problems Displays a list of all active problems that are entered into the Problems module for this patient My Favorites Displays the provider’s personal list of diagnoses that are saved for ease of use and are not specific to the particular patient Parent topic: Add or Update Assessment Template

Add or Update Assessment Template

Recommendations

Behavioral Health Common Assessment Page

Access the Add or Update Assessment Template Based on DSM-5 Standards

DSM-5 Overview

Enter Assessment and Diagnosis Details

Using the Assessments Tab

Grids in Add or Update Assessment Template

Behavioral Health Common Assessment Page

Access the Add or Update Assessment Template Based on DSM-5 Standards

DSM-5 Overview

Enter Assessment and Diagnosis Details

Using the Assessments Tab

Grids in Add or Update Assessment Template