Document Individuals Present

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

Record New Issues

Expand the New Issues panel. Under New issues/stressors/extraordinary events presented today, select from the available statuses. Enter relevant details in the Explanation field. Click the Task button to send an email to a coworker. Parent topic: BH - Contact Note Template Parent topic: BH - Individual Counsel/Psych Prog Note Template Parent topic: Group Visits for Behavioral Health Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)

NextGen® Adaptive Content Engine Help Enterprise 8

Record Vital Signs for the Nurse Progress Note

On the Vital Signs panel, click Historical information entered this encounter to view all vitals for the current encounter. Click History to view a complete history of the client's vitals. Click Add to add a new set of vitals. The Vital Signs (Lite) - [New Record] template appears. The Measured date, Time, and Measured by fields are populated. However, the date and time can be manually changed but the user name in the Measured by field cannot be modified. Enter information using the on-screen numeric keypad. Click the NEXT button below the numeric keypad to enter information in the next field. Select the Carried forward option to pull a previously entered Height into this field. After a Height and Weight value are entered, a BMI value is calculated below the numeric keypad. Select the BMI Plan link to open the Health Promotion Plan template, where an out-of-range BMI can be easily addressed with diet, exercise, and referral information. The Functional Status panel on this template prov

NextGen® Adaptive Content Engine Help Enterprise 8

Sign the Behavioral Health Document

Multiple people can sign the Behavioral Health document utilizing the Signature panel. Security on the Signatures panel is set up so that only the person who checks a signature line can alter it in any way. The client and/or parent/guardian’s signatures can be captured with electronic signature software. To document your signature in the Signatures panel, place a check mark next to the appropriate label. The current user’s name fills the Name field and the current date populates the date of the signature. Enter your Credentials. Select N/A to indicate that a signature is not applicable and to clear the fields of anything that may have been entered in the same row. Click the Send Task button to forward the template to the next person who needs to record their signature. If your signature does not fall under the preset options, enter your Name and Credentials in the Additional Staff section. Enter Comments as needed. Click Add. The signature details appear in the grid. Parent topic: BH -

NextGen® Adaptive Content Engine Help Enterprise 8

Record a Risk Assessment

Any assessment of risk data that was entered previously on the Comprehensive Assessment template set carries forward to the panels found here. On the Risk Assessment panel, if the patient is not a danger to self or other, select the option for Patient is not currently a danger to self, others, or property. Selecting this option sets every field in the section as unavailable. The Encounter field fills with the current date. In the Risk field, select the appropriate type of risk from the list. If there is a need to record a previous risk for the client, select the Past option. CAUTION: Always document past risks before a current assessment. If Past is selected, either an Event Date (even if approximate) or Denied should be populated. If there are no past assessments to document, select the option for Current. Select Denied or Admits. If Denied is selected, the documentation options are all disabled in this section except for the date fields and the Add and Clear buttons. Enter the Event

NextGen® Adaptive Content Engine Help Enterprise 8

Document Medication Information

On the BH - Nursing Note template, navigate to the Medication Information panel and answer the following questions with No, Yes, or N/A (Not Applicable) and enter Comments as needed: Takes medications as prescribed Changes in medical status Reviewed medication name(s), dosage, purpose, and frequency Were medications delivered today - If yes, for what duration Allergic reactions Side effects reported Note: All allergic reactions must be entered in the Allergies module to ensure that they are apparent on future visits. Click the Side effects reported link to open a template on which medication side effects can be documented. Next to Other medications, select from the following options: None Herbal Over the counter Other - and type specifics in the associated field Click the Office Procedures link to launch the My Plan tabbed template set on the Office Procedures tab and document medications administered today. Click Comments to record a medication comment. Do one of the following actions

Document Individuals Present

Recommendations

Enter Assessment and Diagnosis Details

Record New Issues

Record Vital Signs for the Nurse Progress Note

Sign the Behavioral Health Document

Record a Risk Assessment

Document Medication Information

Enter Assessment and Diagnosis Details

Record New Issues

Record Vital Signs for the Nurse Progress Note

Sign the Behavioral Health Document

Record a Risk Assessment

Document Medication Information