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.
Document Alcohol or Drug Use History
Document Confidential Psychiatric Information for Adult Clients
Pediatric Confidential History
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NextGen® Adaptive Content Engine Help Enterprise 8
Pediatric Confidential History
Use the Peds Confidential History template set to document a pediatric patient’s private information. Links are available in the left pane to document substance use, psychiatric/placement, sexual practice, and child abuse history. Note: The patient must meet the practice's set parameters for the Pediatric Age on the Practice Configuration template in order to use the Peds Confidential History templates. Document Pediatric Confidential Alcohol and Drug Details Document Pediatric Confidential Psychiatric History Record Confidential Pediatric Placement History Document Pediatric Confidential Incarceration History Document Pediatric Confidential Sexual History Document Child Abuse/Neglect Parent topic: Confidential Patient History
NextGen® Adaptive Content Engine Help Enterprise 8
Document Confidential Psychiatric Information for Adult Clients
From the left pane on the Confidential – Alcohol/Drug template, click the Psychiatric link. The Confidential – Psychiatric template opens. Confidential - Psychiatric Select the Noor Yes option for the following: History of suicidal thoughts History of homicidal thoughts Diagnosed with psychiatric problem Enter the Psychiatrist name, Therapist name and corresponding Phone number. Select Yes or No for the following queries: Consent for communication between psychiatrist and PCP Consent for communication between therapist and PCP Family Hx of psychiatric problems Select the Abuse/Incarceration, Sexual Practices/STI's, and Provider Comments links from the left pane to document the required details. If the patient provides permission to include the documented information in the social history document, select Include all confidential information in the social history document with patient permission at the top of the template. Note: If you select the Include all confidential information in
NextGen® Adaptive Content Engine Help Enterprise 8
Document Alcohol or Drug Use History
On the Confidential - Alcohol/Drug template, go to the Alcohol Use section. Enter the age on the Age Alcohol Use Began numeric keypad in the Age Started field. Select the No or Yes option for the following queries: Sought treatment for alcohol abuse Involved in a 12-step program Have you had withdrawal problems, seizures or blackouts from alcohol or drugs Emergency medical attention required due to intoxication Family Hx of alcoholism To document treatment, enter the date of the last drug treatment, and the number of times the patient received drug treatment. Under Drug Use/Abuse, select an option to indicate if the patient uses drugs. If the selected option is No, no other documentation is required in this section. If the selected option is Yes or Formerly, document the age at which patient started using drugs, drug type, frequency of drug use and route. Select the Quit check box to indicate that the patient used the associated drug formerly and has quit. Select either Yes or No for t
NextGen® Adaptive Content Engine Help Enterprise 8
Brief Assess Histories Panel
The Histories panel enables you to document confidential client history and past medical, family and social history. The Social Determinants of Health link launches the Social Determinants of Health template. The Social Determinants of Health template provides a prebuilt questionnaire for documenting social, behavioral, and psychological data for the patient. Add Past Medical, Family and Social History in Brief Assessment Confidential Patient History Parent topic: BH - Brief Assessment Template
NextGen® Adaptive Content Engine Help Enterprise 8
Confidential Information
You can use the confidential history templates to document a patient's confidential information. You can open the confidential history templates by selecting the Confidential History link in the Social panel on the Histories template. The following links enable you to document the confidential information of the patient: Alcohol/Drug Enables you to open the Confidential - Alcohol/Drug template. Psychiatric Enables you to open the Confidential - Psychiatric template. Abuse/Incarceration Enables you to open the Confidential - Abuse/Incarceration template. Sexual Practices/STI's Enables you to open the Confidential - Sexual Practices/STIs template. Provider Comments Enable you to add any other confidential information. With the patient's permission, you can generate the documented confidential details in the social history document. You must select the Include all confidential information in the social history document with patient permission check box to include the details in the social
NextGen® Adaptive Content Engine Help Enterprise 8
Confidential Information
You can use the confidential history templates to document a patient's confidential information. You can open the confidential history templates by selecting the following links. The Confidential History link in the Social panel on the Histories template. The Confidential link in the History Summary panel on the Intake template. The links enable you to document the following confidential information of the patient. Alcohol and drug use On the Confidential - Alcohol/Drug template. Psychiatric history On the Confidential - Psychiatric template. Abuse or domestic violence and incarceration On the Confidential - Abuse/Incarceration template. Sexual practices and STI details On the Confidential - Sexual Practices/STIs template. With the patient's permission, you can generate the documented confidential details in the social history document. You need to select the Include all confidential information in the social history document with patient permission check box at the top of the template
