Document Functional and Cognitive Assessments

NextGen® Adaptive Content Engine Help Enterprise 8

Document Pain Assessment and Plan of Care

You can document the pain assessment details and follow-up plan of care. Open NextGen® Enterprise EHR. Open the Intake template. Expand the Vital Signs panel, and then select the Health Promotion Plan link. The Health Promotion Plan template opens. Expand the Pain Management panel. Note: The Pain level and Method fields display the details entered on the Vital Signs template. You cannot update the pain level and method in the Pain Management panel. Pain Management - Health Promotion Plan To manage exceptions and view measure details on the Exceptions/Measures template, select Exceptions. If details are not entered in the Pain level section on the Vital Signs template, select the following fields, and select the appropriate option in the list. Pain level Method Duration Quality To indicate to see the HPI details, select the See HPI check box. Enter the location of the pain of the patient. Select Onset, and select the date when the pain started. Enter the follow-up plan of care for a pat

NextGen® Adaptive Content Engine Help Enterprise 8

Care Plan

You can use the Care Plan templates to address patients' health concerns and monitor their progress toward resolving specific concerns. Patient Care Plans You can create a care plan to address patients' health concerns and monitor their progress toward resolving specific concerns. Manage Health Concerns Manage Goals, Interventions, and Outcomes Patient Care Team Members Document Functional and Cognitive Assessments You can document a patient's functional and cognitive assessments in the Functional and Cognitive Assessment Status panel. Review a Patient's Care Plan History View At A Glance Panel Related concepts Patient Care Plans Manage Health Concerns Manage Goals, Interventions, and Outcomes Patient Care Team Members Review a Patient's Care Plan History Related tasks Document Functional and Cognitive Assessments View At A Glance Panel

NextGen Behavioral Health Suite Help 5.5

Document Patient's Mental Health Details Using the Brief Assessment Template

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Brief Assessment (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether you have discussed confidentiality and obtained patient's consent for the care. To document the patient's past medical history, select the History Summary link. In the Presenting Concerns panel, do one of the following actions in the Written HPI narrative field: Enter the patient's symptoms and presenting issues that prompted a visit to the office. Use the My Phrases link to select the details for the visit. In the Substance Use/Addictive Behavior panel, select the patient's addiction details to substances. Select the patient's current experiences on physical and domestic violence and other trauma details in the Trauma History panel. Enter the patient's mental status evaluation findings. Comp

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Assessment Plan Details

Open NextGen® Enterprise EHR. On the Assessment Plan Details template, select the A/P Details tab. To add or change a diagnosis in the Today’s Assessments grid, select Add or Edit to open the Add or Update Assessment template. To change the current working assessment, in the Today's Assessments grid, select the diagnosis being addressed for this encounter. The selected diagnosis appears in the Selected Dx field. It becomes the new working assessment that carries forward to the other templates that share the assessment. Enter details manually or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections. To enter follow-up appointment and disposition information, select Follow Up. To document counseling educational details and factors, select the Counseling Details link. To enter post-operative details, select the Postoperative Quality Reporting link. For more information on the associated quality measure, selec

NextGen Behavioral Health Suite Help 5.5

Document Information about the Patient's Skill Assessment

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select IDD Functional Skills Assessment (BH), and then select OK. Note: You can open the IDD Functional Skills Assessment (BH) template from your Packet Navigation, or from the Templates module. For more information on configuring Packet Navigation, go to NextGen Healthcare Success Community, and download the Configuration Guide for NextGen® Behavioral Health Suite. In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time. Note: You can select the current time or enter the time manually. Select the program, specialty, and visit type. Note: Only programs that the patient is actively enrolled in appear in the list. You can select <No Program> to create an encounter without a program, and then add the program later. In the Individuals Present panel, document the details of the individuals present d

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Mental Health and Risk Assessment Information

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Comp Assess - BH Hx, and then select OK. To document the patient's medical and surgical details in the Past Medical/Surgical panel, select Add. Note: To document the patient's mental and physical health details, you can select the corresponding links in the Past Medical/Surgical panel. In the Substance Use/Addictive Behavior History panel, document the details about the patient's addiction to substance use. In the Mental Health and Addiction Treatment Service panel, document the patient's treatment details about the mental health and substance use. In the Medication Information panel, review and update the patient's medication details. In the Mental Status Evaluation panel, enter the patient's mental health details. Note: To document the patient's mental health status systematically, you can select the Mental s

Document Functional and Cognitive Assessments

Recommendations

Document Pain Assessment and Plan of Care

Care Plan

Document Patient's Mental Health Details Using the Brief Assessment Template

Enter Assessment Plan Details

Document Information about the Patient's Skill Assessment

Document the Patient's Mental Health and Risk Assessment Information

Document Pain Assessment and Plan of Care

Care Plan

Document Patient's Mental Health Details Using the Brief Assessment Template

Enter Assessment Plan Details

Document Information about the Patient's Skill Assessment

Document the Patient's Mental Health and Risk Assessment Information