Document an Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Open the Assessments Tab

There are several options for accessing the Add or Update Assessments template: On the SOAP template, in the Assessment / Plan panel, select Add/Update. On the Intake or SOAP templates: Select the My Plan link to open the template set. My Plan Select the Assessments tab. Change the Order of Assessments in the Grid Convert ICD Codes in the Billing History Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the Today's Assessment grid in theAdd or Update Assessment template. Entering Assessments, Impressions, Differential Diagnoses, and Associated Details Links and Buttons on the A/P Details Tab Open the Assessment / Plan Details Template Parent topic: Add or Update Assessment Template Parent topic: Using the Assessments Tab

NextGen® Adaptive Content Engine Help Enterprise 8

Select an Assessment from Billing Diagnosis History

On the Add or Update Assessment template, Billing Diagnosis History section, select an existing diagnosis from the grid. To open the Common Assessment template, click Add common assessment. Add or Update Assessment The template opens to the page associated with the currently selected Specialty and gender and age of the patient. To view a different page, click the Common assessments field to open a picklist of assessment page options. Common Assessment Click Save & Close to close the Common assessment page. To open the diagnosis search window, click Diagnosis Code Lookup. For more details on searching for diagnoses in the window, go to NextGen Healthcare Success Community to download the latest Problems Module User Guide for NextGen® Enterprise EHR. Select the line item in the grid to fill the ICD description and ICD Code fields. Continue documenting the assessment on the Assessments tab. Convert ICD Codes in the Billing History Parent topic: Document an Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Using the Assessments Tab

The Assessments tab in the My Plan template set houses the Add or Update Assessment template. The grids on the Assessments tab can be filtered. For example, in the Billing Diagnosis History section, selecting the Show Chronic only check box displays only those diagnoses that are not acute. Selecting the option to Add Assessments on 1 click speeds up the documentation process by including the diagnosis description and code for Today's Assessment in the grid and Problems module without having to click Add/Update. The Medications or Immunizations links can be used at any time during the encounter to access the associated module. Open the Assessments Tab Document an Assessment You can document an assessment on the Add or Update Assessment template. Shared Working Assessment The group of templates that share the selected assessment for the patient. Change the Order of Assessments in the Grid Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the To

NextGen® Adaptive Content Engine Help Enterprise 8

Select an Assessment from My Favorites

On the Add or Update Assessment template, My Favorites section, you can leave the Favorites category on All or change it to another category. Assessments To further reduce the number of items in the grid, click the Filter field to type a search value. For example, type the first letter of the diagnosis into the Filterfield to return only the favorite assessments beginning with that letter into the grid. Highlight the line item in the grid to populate the ICD description and ICD Code fields. Continue documenting the assessment on the Assessments tab. Parent topic: Document an Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Update the Assessment Details in Today's Assessments grid

If you want to update the assessment details in the Today's Assessments grid, Highlight an assessment in the Today's Assessments grid. Select or enter appropriate value in the Status, Side, Site, Impression, Differential Dx fields. Click Update. If the diagnosis is chronic, select the Mark diagnosis as chronic check box. If you want to add the selected assessment to the problem list, tracked problems, and/or favorite list, select the Clinical problems, My tracked problems, and/or My favorites check box respectively. Note: You can click the other tabs such as My Plan, A/P Details, and so on to document treatment plan, prescribe medications, order labs or X- rays, and request referrals. Parent topic: Upload the Procedure Diagnosis in Today's Assessment Grid

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

Document an Assessment

Recommendations

Open the Assessments Tab

Select an Assessment from Billing Diagnosis History

Using the Assessments Tab

Select an Assessment from My Favorites

Update the Assessment Details in Today's Assessments grid

Add Diagnostic Details

Open the Assessments Tab

Select an Assessment from Billing Diagnosis History

Using the Assessments Tab

Select an Assessment from My Favorites

Update the Assessment Details in Today's Assessments grid

Add Diagnostic Details