Add Trauma History on the Brief Assess

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Record Substance Use and Addictive Behavior Histories

On the Substance Use/Addictive Behavior History panel, select the None reported check box if the client denies substance use or addictive behavior. Select one or more of the addictions options reported by the client. If needed, Other can be selected to type an historical issue that is not available on the panel in the associated field. Select the client's response for Drinks alcohol. If no information has been entered for the client's tobacco use history elsewhere, the read-only field is blank; to enter this data, click the Tobacco Usage link. If any of the addiction options apply, click the Substance Use link available at the top, right of the panel to gather more details. The BH Substance Use Assessment template opens. Enter Tobacco Usage Parent topic: BH - Brief Assessment Template Parent topic: BH - Psychiatric Evaluation

NextGen® Adaptive Content Engine Help Enterprise 8

Brief Assess Histories Panel

The Histories panel enables you to document confidential client history and past medical, family and social history. The Social Determinants of Health link launches the Social Determinants of Health template. The Social Determinants of Health template provides a prebuilt questionnaire for documenting social, behavioral, and psychological data for the patient. Add Past Medical, Family and Social History in Brief Assessment Confidential Patient History Parent topic: BH - Brief Assessment Template

NextGen® Adaptive Content Engine Help Enterprise 8

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

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

Maintain a Record of the Client's Trauma History

The data in this panel copies forward from previous encounters and shares with the same panel on the Brief Assessment template. Expand the Trauma History panel. Trauma History If there is no history of trauma, select None reported to set the options below for the different types of experiences to be unavailable. Document the client's history and current experience of trauma in the Does individual report a history of, or current experience of section If Other is selected, an explanation or description can be typed into the adjacent field. Other pertinent information can be entered in the Provide relevant details field. Parent topic: Social Hx of a Comprehensive Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

BH - Brief Assessment Template

The BH- Brief Assessment template enables providers, case workers and social workers, to document on an abridged version of the Comprehensive Assessment template set. Because a comprehensive exam takes a significant amount of time (more than a single client visit), the BH - Brief Assessment template can be used to complete the evaluation during one encounter. Start a New Intake for a Brief Assessment Record the Client's Presenting Concerns Brief Assess Histories Panel Record Substance Use and Addictive Behavior Histories Enter Tobacco Usage Add Trauma History on the Brief Assess Record Mental Status Exam Information Record a Risk Assessment Enter Assessment and Diagnosis Details Enter Treatment Plan Information Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Intake Visits for Behavioral Health

Add Trauma History on the Brief Assess

Recommendations

Record Substance Use and Addictive Behavior Histories

Brief Assess Histories Panel

Record a Risk Assessment

Enter Assessment and Diagnosis Details

Maintain a Record of the Client's Trauma History

BH - Brief Assessment Template