Complete Behavioral Health Screenings on the Screening Tools Panel

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Document Mental Health and Addiction Treatment Service Histories

On the Mental Health and Addiction Treatment Service History panel, do one of the following: Place a check mark for None reported. In the Treatment services history within the past five years section, enter as much information acquired from the client in the fields. Type of service is the only required field in this section. Click Add. In the Outpatient section, select Not applicable or enter the Age at time of initially seeking outpatient treatment services. Enter the Total number of lifetime outpatient treatment experiences. In the Inpatient section, select Not applicable or enter the Age at time of initial inpatient treatment. Click the Total number of lifetime inpatient treatment experiences field to enter a value. In the Er/detox section, select Not applicable or enter the Total number of er visits in the last 6 months. Enter the Number of non detox hospital days in the past 6 months and select a reason. Medical Psychiatric Both Click the Number of days the client has been in drug

NextGen® Adaptive Content Engine Help Enterprise 8

Substance Use Assessment Exam

BH Substance Use Assessment is a template on which a clinician or nurse can gather information about a client’s substance use history and how an addiction might negatively impact the client’s life. The information gathered on this template is configured to appear on whatever document is generated. It is one of just a few templates that launches with all but the top panel collapsed. This was done to make it easier find and use the appropriate panel. The recommended workflow is to expand a panel to document the information and collapse it when that section is complete. This template is launched from a Substance use link found on the Substance Use/Addictive Behavior panel. This link is also available on many templates throughout the Behavioral Health template set. Enter Chemical Use/Abuse History Add Substance Use Data Document Tobacco Use on the Substance Use Assessment Exam Add Gambling Information Document Impact of Substance Use/Addictive Behaviors of Life Areas Enter Toxicology Scree

NextGen® Adaptive Content Engine Help Enterprise 8

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. Use the Other field 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. Click the Tobacco Usage link to enter the client's tobacco use. If any of the addiction options apply and a more in-depth evaluation is required, click the Substance Use link to enter more details. The BH Substance Use Assessment template launches. Enter Tobacco Usage Parent topic: BH Hx Section Tab Overview

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

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

NextGen® Adaptive Content Engine Help Enterprise 8

Document Impact of Substance Use/Addictive Behaviors of Life Areas

On the BH Substance Use Assessment template, expand the Impact of Substance Use/Addictive Behaviors of Life Areas panel. Under the Life area section, click Yes or No for Vocational/educational employment. To enter additional information, click the If yes, please describe field. Click Yes or No for Interpersonal/family relationships and enter an explanation in the associated field. Click Yes or No for Usual per group and/or environments and type an explanation in the associated field. Click Yes or No for Mental health and enter additional details in the associated field. In Life areas, click Yes or No for the following items: Legal, Medical/physical, Housing, Behavioral condition(s) Other functional impairments Enter an answer in the What recovery environment features serve as a resource or obstacle to recovery, including family members' use of alcohol or other substances field. Click the Degree of addiction severity field to enter data. Document the Recommendation for level of care. Pa

Complete Behavioral Health Screenings on the Screening Tools Panel

Recommendations

Document Mental Health and Addiction Treatment Service Histories

Substance Use Assessment Exam

Record Substance Use and Addictive Behavior Histories

Record a Risk Assessment

BH Hx Section Tab Overview

Document Impact of Substance Use/Addictive Behaviors of Life Areas

Document Mental Health and Addiction Treatment Service Histories

Substance Use Assessment Exam

Record Substance Use and Addictive Behavior Histories

Record a Risk Assessment

BH Hx Section Tab Overview

Document Impact of Substance Use/Addictive Behaviors of Life Areas