BH - Psychopharm Template

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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

NextGen® Adaptive Content Engine Help Enterprise 8

Nurse's Progress Note (Short)

The BH - Nursing Note Short template is a quick solution to document an encounter for a client who does not have any major changes since their last visit. The shortened version of the progress note includes the following panels: Program Name Vital Signs Individuals Present New Issues Goals, Objectives, and Interventions Addressed Today Assessment/Diagnosis Plan and Additional Information Signatures The Behavioral health billing section is available at the bottom of the BH - Nursing Note Short template. Enter the Program Name Record Vital Signs for the Nurse Progress Note Document Individuals Present Record New Issues Enter Goals, Objectives and Interventions Addressed Today Enter Assessment and Diagnosis Details Enter Plan of Care and Additional Information Sign the Behavioral Health Document Finalize Billing for Nurse Notes Parent topic: Behavioral Health Medication Management

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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

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

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BH Hx Section Tab Overview

The Behavioral Health History (Bh Hx) section tab enables you to document the client's mental health history, substance use, risk assessment and to complete various screening tools. From this tab, users have access to the Past Medical History, Substance Use Assessment Exam, Social History - Tobacco, and Mental Status Exam templates. Enter Psychiatric Illness History Data Record Substance Use and Addictive Behavior Histories Substance Use Assessment Exam Document Mental Health and Addiction Treatment Service Histories Medication Information Panel Mental Status Evaluation Panel Record a Risk Assessment Enter Risk and Alert Histories Complete Behavioral Health Screenings on the Screening Tools Panel Parent topic: Comprehensive Assessment Template Set

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The BH - IAP Review/Revision Template

The BH - IAP Revision/Review template is used to document progress or lack thereof and demonstrates evidence and/or rationale for the amendment of treatment goals and objectives in the Individual Action Plan (IAP). The system automatically pulls forward data from the last IAP or IAP review to the current encounter. Use this template to update or modify the IAP in any of the following ways: Revisions – work with the client to add a new goal; change goals, objectives, or interventions; or to change the frequency or duration of services Reviews – record the progress of the client, therefore facilitating the identification and tracking of treatment goals and objectives Visit Types for the BH - IAP Review/Revision Template Start an IAP Revision/Review Document Assessed Needs, Goals, Objectives and Interventions Add a New Goal for IAP Reviews Document Interventions for IAP Reviews Enter Methadone & Assertive Community Treatment Program Information Record Transition/Discharge Criteria Enter D

BH - Psychopharm Template

Recommendations

Nurse's Progress Note (Long)

Nurse's Progress Note (Short)

BH - Brief Assessment Template

BH - Psychiatric Evaluation

BH Hx Section Tab Overview

The BH - IAP Review/Revision Template

Nurse's Progress Note (Long)

Nurse's Progress Note (Short)

BH - Brief Assessment Template

BH - Psychiatric Evaluation

BH Hx Section Tab Overview

The BH - IAP Review/Revision Template

BH - Psychopharm Template