BH - Brief Assessment Template

NextGen® Adaptive Content Engine Help Enterprise 8

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

BH - Psychopharm Template

The BH - Psychopharm template is intended for the Behavioral Health prescriber to document a follow-up visit. The interventions can be tied to the client's treatment plan, but the content is specific to the needs of psychiatric professionals who prescribe medication. Access the BH - Psychopharm Template Enter Program Information Record Vital Signs for the Nurse Progress Note Document Individuals Present Record Mental Status Exam Information Enter the Prescriber's Evaluation Record a Risk Assessment Document Medication Information Enter Assessment and Diagnosis Details Enter Goals, Objectives, and Interventions Addressed Today Record Plan Details Enter Document Signatures Parent topic: Behavioral Health Medication Management

NextGen® Adaptive Content Engine Help Enterprise 8

Screening and Admission Visit Workflow

The BH - Screening/Admission Note template is used to document information that a program or Emergency Room might need for their initial evaluation of a client. Information gathered here is the basis for a summarization of the services and possible interventions that are initially provided to the client. Generally, this is completed by the non-clinical staff at the practice and can be done separately from a Comprehensive Assessment exam. The BH - Screening/Admission Note template can be accessed at any time during an encounter by selecting Other Templates from the bottom section of the navigation bar. Document Admission Data Document Referral Source Enter Assessment and Diagnosis Details Add Additional Notes Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

BH - Individualized Action Plan (IAP) Template

The Individualized Action Plan (IAP) template is the master treatment plan of care for the client. Following the Comprehensive Assessment exam, the Behavioral Health provider may choose to initiate an IAP. The IAP is completed in collaboration with the Behavioral Health client and a copy of the finished plan is usually signed by the client. The action plan template enables users to leverage electronic functionality by tying together the data across the client’s assessment, IAP, and Progress Note. Because this information is shared, the user is not repeatedly entering the same data. Visit Types for Individualized Action Plan Complete the IAP General Panel Document Assessed Needs, Goals, Objectives and Interventions Enter Goal Information Record Objective Information Document Interventions, Methods, and Actions Other Functional Areas Not Applicable/Methadone Treatment Transition/Discharge Criteria Panel Enter Document Signatures Parent topic: Intake Visits for Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

BH - Individual Counsel/Psych Prog Note Template

The BH - Individual Counsel/Psych Prog Note template enables you to document individual counseling services and the client's progress or the lack thereof. Any risk assessment, goals, objectives, or assessment data that was entered previously on the Comprehensive Assessment template set populates in the panels found on the Progress Note tab. You can document new issues and make updates to the goals, objectives and interventions. Use the Behavioral health billing section to submit billable service codes to the Superbill. The Progress Note tab can be a stand-alone template or used in conjunction with the other tabs or links. Enter Program Name Record Individuals Present Update the Client's Current Assessment Record a Risk Assessment Record New Issues Enter Goals, Objectives and Interventions Addressed Today Document Plan and Additional Information Enter Assessment and Diagnosis Details Sign the Behavioral Health Document Complete Behavioral Health Billing Parent topic: Individual Visit Wo

NextGen® Adaptive Content Engine Help Enterprise 8

Nurse's Progress Note (Long)

While the long and short notes were primarily designed for nurses working within a practice that provides psychiatric medication management, there are many other instances where using these templates would be appropriate. The BH - Nursing Note template (long note) should be used when it is apparent that there has been a significant change in the client's status. The long version of the template enables the documentation of vital signs and other medication concerns that may need to be conveyed to the psychiatric prescriber. Both versions of the nursing note are available from the navigation bar. Enter the Program Name Record Vital Signs for the Nurse Progress Note Document Individuals Present Enter an Interim Update Record New Issues Update the Client's Current Assessment Record a Risk Assessment Document Medication Information Enter Patient Allergy Data Enter Goals, Objectives and Interventions Addressed Today Enter Plan of Care and Additional Information Enter Assessment and Diagnosis

BH - Brief Assessment Template

Recommendations

BH - Psychiatric Evaluation

BH - Psychopharm Template

Screening and Admission Visit Workflow

BH - Individualized Action Plan (IAP) Template

BH - Individual Counsel/Psych Prog Note Template

Nurse's Progress Note (Long)

BH - Psychiatric Evaluation

BH - Psychopharm Template

Screening and Admission Visit Workflow

BH - Individualized Action Plan (IAP) Template

BH - Individual Counsel/Psych Prog Note Template

Nurse's Progress Note (Long)