Brief Assess Histories Panel

NextGen® Adaptive Content Engine Help Enterprise 8

Add Trauma History on the Brief Assess

The data in this panel copies forward from previous encounters and shares with the same panel on the Comprehensive Assessment, Social History section tab. On the Trauma History panel, if there is no history of trauma, select the check box for None reported to set the options below for the different types of experiences to be unavailable. Select the Yes for each item that is reported by the client. If Other is selected, an explanation or description can be typed into the adjacent field. Enter other pertinent information into the Provide relevant details field. Parent topic: BH - Brief Assessment Template

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

NextGen® Adaptive Content Engine Help Enterprise 8

Add Past Medical, Family and Social History in Brief Assessment

All of the grids available through the navigation pane on the Histories Summary panel share data and copy forward to the next encounter for the current patient. In the History Summary panel, to indicate what detailed history information prints in the generated document, click the History Review button to open the Histories template. If there is no relevant history, select No relevant past medical/surgical history. Click the Confidential link to record private information provided by the patient during the course of encounter. Note: For an adult patient, the Confidential template set opens, for younger patients, the Peds Confidential History template is launched. The grid defaults to the Past Medical/Surgical view (indicated by the black arrow icon in the navigation pane). To filter the past history records in the grid, select Medical History or Surgical History. By default, the Show All check box is selected. Click the Add button to enter data on the Past Medical History template. To e

NextGen® Adaptive Content Engine Help Enterprise 8

Confidential Patient History

Use the Confidential template set to document an adult patient’s private information, including their alcohol and drug use, psychiatric, abuse, incarceration, and sexual practice/STI's histories. Confidential - Alcohol/Drug Document Alcohol or Drug Use History Document Confidential Psychiatric Information for Adult Clients Pediatric Confidential History Parent topic: Brief Assess Histories Panel

NextGen® Adaptive Content Engine Help Enterprise 8

Patient's Social History

You can document a patient's social history. You can open the individual social history template or the Adult Social History template to document the social history information of a patient. The Adult Social History template includes the existing social history templates arranged in a one-page panel format. Each panel includes the data fields from the respective social history template. You can choose to document the social history information of the patient on individual social history templates or on the Adult Social History template. You can document the following social information for an adult patient on the social history templates or the Adult Social History template: Tobacco/Vaping Use Alcohol/Caffeine Statuses Lifestyle Occupation Comment Diet History Environmental Note: NextGen® Adaptive Content Engine is packaged with the individual social history templates as the default social history templates. However, the practice can configure the Practice Configuration template to set

NextGen® Adaptive Content Engine Help Enterprise 8

Histories Template

Patient history information is documented on the Histories template for a new patient, and reviewed and updated for an existing patient. Histories Patient's Problem List You can manage a patient's problems. Patient's Medical History The Medical/Surgical/Interim panel enables you to document the medical or surgical history of the patient. Patient's Diagnostic Tests and Results You can document a patient's diagnostic tests and the associated results. Patient's Family History You can document the family history of the patient in the Family panel on the Histories template. Document the Social History of the Patient You can document the social history of a patient from the Social panel on the Histories template. Parent topic: Physical Therapy

Brief Assess Histories Panel

Recommendations

Add Trauma History on the Brief Assess

BH - Brief Assessment Template

Add Past Medical, Family and Social History in Brief Assessment

Confidential Patient History

Patient's Social History

Histories Template

Add Trauma History on the Brief Assess

BH - Brief Assessment Template

Add Past Medical, Family and Social History in Brief Assessment

Confidential Patient History

Patient's Social History

Histories Template