Document Functional Status Assessment for Chronic Conditions

NextGen® Adaptive Content Engine Help Enterprise 8

Document Functional and Cognitive Assessments

You can document a patient's functional and cognitive assessments in the Functional and Cognitive Assessment Status panel. The data entered in the Functional and Cognitive Assessment Status panel is shared with the Health Promotion Plan, Medicare Preventive HPI, Screening Summary, and Care Plan templates to measure compliance and for surveillance reporting. 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 Functional and Cognitive Assessment Status panel. Functional and Cognitive Assessment Status For Functional Status and Cognitive Status, do the following: If there is no change in the functional status of the patient, select No Change. If there is a change in the functional status or cognitive status of the patient, select Change. Select the Status field, and select the appropriate option from the list. Enter the assessment method and used method. T

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

Title X 2.0 Template Overview

The Title X 2.0 template displays all the Title X 2.0 clinical information recorded for a patient during a family planning encounter. You can review the present and previously recorded patient details for Family Planning Annual Report (FPAR) 2.0. The patient’s recorded Title X 2.0 information is categorized into various panels, such as General, Social History, Confidential History, Assessment / Plan Vital Signs, and Testing and Results. The Title X FPAR 2.0 report is required under the Title X Service Grants and is generated by all family planning clinics receiving the Title X grants. The Office of Population Affairs (OPA) requires all Title X grantees to collect and submit FPAR data at the encounter level for the yearly reporting period, starting January 1 through December 31. The Title X FPAR report 2.0 must be set up and licensed for your practice. When the Title X 2.0 software is installed, the lab tests and the results also appear on the Title X 2.0 template. The LOINC® and SNOMED

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

NextGen® Adaptive Content Engine Help Enterprise 8

Review and Document Responses to Screening Questions

You can review and document responses to patient condition using Screening Questions panel. Open NextGen® Enterprise EHR. Select the Care Guidelines link on any of the main template. The Care Guidelines Paged View template opens. In the Care Guidelines panel, select the Grid View link. The Care Guidelines grid view template opens. Select a disease or condition guideline listed in Outstanding Guidelines. If screening questions are configured for the guideline, they appear on the Screening Questions panel when you select the guideline. Note: Not all guidelines have screening questions associated with them. Care Guidelines For each question you choose, document the patient response. Select the appropriate No or Yes check box corresponding to the question. To enter a very brief comment, select the Comments field corresponding to the question and enter text. Select Save. Repeat steps 2 – 4 for each guideline. Parent topic: Screening Questions

Document Functional Status Assessment for Chronic Conditions

Recommendations

Document Functional and Cognitive Assessments

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

Title X 2.0 Template Overview

Document Information about the Patient's Skill Assessment

Document the Patient's Mental Health and Risk Assessment Information

Review and Document Responses to Screening Questions

Document Functional and Cognitive Assessments

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

Title X 2.0 Template Overview

Document Information about the Patient's Skill Assessment

Document the Patient's Mental Health and Risk Assessment Information

Review and Document Responses to Screening Questions