Complete the Diagnoses Section for Transfer/Discharge

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Assessment and Diagnosis Details

Expand the Assessment/Diagnosis panel. If enabled, click the DSM IV link in the upper, right corner to launch the BH – DSM IV template. Note: The display of the link is set up on the Behavioral Health section of the Practice Configuration system template. In the Behavioral Health Diagnoses section, select any of the available links. In the Diagnostic description required field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. Add Status, Severity, Differential DX, and Impression. The out-of-the-box Severity picklist does not include Extreme or Persistent. These values can be added to the list in File Maintenance. Enter any required Specifiers by doing one of the following actions: Click the field to type a value. Click the My Phrases link to create a new sentence or part of a sentence. For more information about My Phrases, go to NextGen Healthcare Success Community and download the latest Getting Start

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Transfer/Discharge Data

The assessment and diagnosis information of the client being transferred or discharged can be entered on the BH - Transfer/Discharge 1 template. Select the Transfer or Discharge option. Enter a Date. Select from one of the available statuses or choose Other to type an explanation of the client's situation. If enabled, click the DSM IV link that appears in the upper, right corner to launch the BH – DSM IV template. The display of the link is setup on the Behavioral Health section of the Practice Configuration system template. Complete the Diagnoses Section for Transfer/Discharge Enter a Discharge Summary and Treatment Enter Post Discharge Support Systems for the Client Record the Client's Discharge Risk Assessment Document Known Substance Use for Transfer/Discharge Summary Parent topic: Transfer or Discharge Visit Workflow

NextGen Behavioral Health Suite Help 5.5

Add Diagnostic Details

In the Assessment/Diagnosis panel, confirm the assessment selected displays in the Description details and ICD Code field. If not, select the assessment in the grid to fill in the details. Add Status, Severity, Differential Dx, and Impression. To enter specifiers in the Specifiers field, do one of the following: Select in the field and enter free text. Select the My Phrases link and select a phrase from the list. If applicable, select Present on Admission and then select a description from the list. To indicate the diagnosis is chronic, add the diagnosis to the client’s clinical problems list, and/or add the assessment to my tracked problems, select the respective checkbox. Select Add To Grid. The information displays in the grid. To add psychosocial stressors, select the Psychosocial Stressors link. To add referrals, select the Referrals link. To reorder the diagnoses, select Sort. To update a diagnosis, select the diagnosis in the grid, modify the details, and select Update. Parent t

NextGen® Adaptive Content Engine Help Enterprise 8

Document Physical Health Diagnoses and Psychosocial Stressors

Navigate to the Assessment/Diagnosis panel. In the Physical Health Diagnoses Affecting Behavioral Health section, click the first available field to open the BH - Reported By Patient picklist and select a value. Click Psychosocial Stressors to enter psychosocial stressors and related details. To document a referral, click the Referrals link. Physical Health Diagnoses Affecting Behavioral Health in the Assessment/Diagnosis Panel Note: The Current GAF and Highest GAF in past year field values carry forward to future encounters. Click the GAF Scale link to review descriptions of how the GAF score is calculated. Click either field, Current GAF or Highest GAF in the past year, to enter a value. The current encounter date automatically fills the corresponding date field. Parent topic: Enter Assessment and Diagnosis Details

NextGen® Adaptive Content Engine Help Enterprise 8

Enter DSM IV Assessment Details

In the Assessment/Diagnosis panel, click the DSM IV link to open the BH - DSM IV template. In the Axis I & II section, click the Copy Forward button to pull in previously entered assessment/diagnosis. Note: This button is enabled only if there is data available from a previous encounter. To open the Common assessment template, click Add Common Assessment. To document information for any person who should be contacted concerning this client, click Mandated Care Coordination. To enter a new diagnosis, click Add to open the Add or Update Assessment template. After a diagnosis has been entered, click Save & Close to return to the BH - DSM IV template. Do one of the following in the Axis III section: In the first available Diagnoses field, click to launch the diagnosis search window. Since the exact code for the client’s non-behavioral health diagnosis may not be apparent, you may not be able to select an Axis III diagnosis code. If available, select a code that was previously entered from

NextGen Behavioral Health Suite Help 5.5

Add an Existing Diagnosis to the Current Encounter

Open NextGen® Enterprise EHR. For a patient encounter, open an assessment template. From the Assessment/Diagnosis panel, select a diagnosis in the Active Diagnosis grid. The Diagnostic description and ICD Code field fills in. Alternatively, in the Last Encounter Diagnosis for Current Provider section, select Copy Forward. Note: When all the diagnoses from the last encounter for the current provider are active, the data is forwarded to the Diagnosis grid. If one or more such diagnosis is not active, the Copy Forward button is not available. You can select the diagnoses manually to add them to the Diagnosis grid. Add Status, Severity, Differential Dx, and Impression. To enter specifiers in the Specifiers field, do one of the following: Select in the field and enter free text. Select the My Phrases link and select a phrase from the list. In the Present on Admission field, select a description from the list. The Description field fills in based on the selection made. Select admitting diagn

Complete the Diagnoses Section for Transfer/Discharge

Recommendations

Enter Assessment and Diagnosis Details

Enter Transfer/Discharge Data

Add Diagnostic Details

Document Physical Health Diagnoses and Psychosocial Stressors

Enter DSM IV Assessment Details

Add an Existing Diagnosis to the Current Encounter

Enter Assessment and Diagnosis Details

Enter Transfer/Discharge Data

Add Diagnostic Details

Document Physical Health Diagnoses and Psychosocial Stressors

Enter DSM IV Assessment Details

Add an Existing Diagnosis to the Current Encounter