Assess/Plan Section Tab

NextGen® Adaptive Content Engine Help Enterprise 8

Explanation of the Functional Section Tab

The information documented on the Functional section tab helps in determining the client’s needs and setting up goals and objectives that are an integral part of the recovery plan. Each panel on the Functional section tab is structured similarly. Items are listed and the question is asked of each item: Not clinically indicated (NI) and Current need area (CN). To understand the difference between NI and CN, look at this example of each in case of Individual care skills: NI - The client shaves and maintains a clean appearance. CN - The client does not want to wear any clothes. A field is available to right of each item in which evidence to justify whether NI or CN can be typed. To the right of this field are No and Yes options to answer Individual/family served desires change now for each item. None of the questions are mandatory. Enter Activities of Daily Living Assign Clinical Assessment of Addictive Behaviors Assign Clinical Assessment for Behavior Management Record Family and Social

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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

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Document the Summary of the Patient's Assessments

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Comp Assess - Assess/Plan, and then select OK. In the Life Goals, Strengths, Abilities and Barriers panel, enter the details of the patient's life goals, strengths, abilities, and barriers. In the Barriers to Care panel, document the obstacles to the patient's care. In the Service panel, enter the patient's care preferences and environmental support details. In the Clinical Formulation/Interpretative panel, document the patient's clinical summary. In the Treatment Recommendations/Assessed Needs panel, document recommendations for the patient's treatment and follow-up evaluations. Select Generate Document. Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates

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Enter Goal Information

When populating data in the Goal Information panel, it is important to note that need and intervention data is not mandatory to complete the plan, but, goals are required. Assessed needs can also be entered on the Comprehensive Assessment template, on the Assess/Plan tab, Treatment Recommendations/Assessed Needs panel, during the intake process. In the Goal Information panel, click the Linked to assessed need field to highlight a value in the resulting list and then click OK. The read-only From form dated and Need source fields pull from information entered during the Comprehensive Assessment exam. In the Functional area field, click to select a value from the list. In the Goal field, select an item that is associated with the assessed need or manually type a goal. Set the Start date and a Target completion date for the goal. If the start and target dates are not entered before selecting an Adjusted target date, the system throws an alert. Set an Adjusted target date and fill in the va

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Document Information in the Assessment/Plan Panel

The Assessment/Plan panel enables you to enter an assessment, generate the prenatal record, enter a follow-up appointment if not already done on the OB flowsheet, document which hospital the prenatal record must be sent to, and task to send the prenatal record to the hospital. The Prenatal Record button generates the cumulative Obstetric document for the pregnancy to date. At the first visit, it is important to generate the Prenatal Record to review all of the information for completeness and accuracy. After reviewing the Prenatal Record, the provider may note data that was not entered or view information that must be entered in the Problem/Detail list for easy viewing at subsequent visits. Select the Prenatal Detail tab Select the Assessment/Plan tab. Assessment/Plan panel To add an assessment, select Add/Update. Select any diagnosis in the Billing Diagnosis History section, the Clinical Problems section or the My Favorites section. Add or Update Asssessment The diagnosis is added to

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Enter Treatment Recommendations

The Treatment Recommendations/Assessed Needs panel enables the delineation of assessed needs, their priority, their status, the date identified, the rationale for not addressing a particular need, and the date resolved. The priority, assessed need and status are required fields if this section is used. If no recommendations are indicated, select No additional recommendations clinically indicated. To enter an assessed need, click the Priority field to type a number. Free text an explanation in the Assessed Need field. In the Status field, select a value from the Need status list. Enter a date in the Identified field. If the need has been declined, deferred, or referred out, enter a Rationale. If the assessed need is resolved, enter the Resolved date. Enter other assessed needs if required. To manage existing assessments, highlight a row in the grid and click Update or Remove. To delete data from the related fields before it is saved to the grid, click Clear. Select any Further evaluatio