Document Individuals Present

NextGen® Adaptive Content Engine Help Enterprise 8

Document Treatment Recommendations/Assessed Needs

On the Treatment Recommendations/Assessed Needs panel, if appropriate, select No additional recommendations clinically indicated. To create a new entry, click the Priority field to enter a number. Type an Assessed Need. In the Status field, click to select a value from the Need status list. Enter a date in the Identified field. If applicable, enter Rationale(s) and/or a Resolved date. Click Add. Repeat steps 1 - 6 as needed. In the Further Evaluations Needed section, do one of the following: Select None indicated. Place a check mark next to any of the applicable options. Enter details in the Level of care/indicated service recommendations field. Type a summary in the Individual served/guardian/family response to recommendations field. In the Treatment Planning Updates section, select No or Yes to Change in IAP Required. If Yes is selected, complete the IAP revision by clicking IAP Review at the top of the template. Parent topic: BH - Psychiatric Evaluation

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Document Signatures

Multiple people may be required to sign the encounter. 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 name of the user who is logged on to the computer fills in the name field, along with the date of the signature. After ‘signing’, you can send a task to the next person who has to sign off. Electronic signature software can be used to capture the signature for the client or parent/guardian. In the Signatures panel, place a check mark next to the label(s) that apply. If needed, enter or modify any Credentials to further identify a signature. To indicate that signature is not applicable and clear the fields of anything that may have been entered in the same row select N/A. Click the Send Task button to forward the template to the next person in line to sign off. If your signature does not fall under the preset options, use the Additional Staff section. Name and Date are required fields. Enter any additional Comm

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Psychiatric Evaluation Presenting Concerns

The Presenting Concerns panel enables you to document the symptoms and presenting issues, in the client's own words, which prompted a visit to the office in the Reason for referral field. In the Presenting Concerns panel select No or Yes to answer the question: Comprehensive Assessment has been completed. If Yes, enter the date of the most recent assessment into the field. In the Reason for referral and chief complaint field, click to enter or dictate notable symptoms, presenting problems, behavioral and functional needs, etc. Enter Family/guardian description of problem. For History of present psychiatric illness, do one of the following actions: Select None reported. Enter or dictate history details. Parent topic: BH - Psychiatric Evaluation

NextGen® Adaptive Content Engine Help Enterprise 8

Document Individuals Present

In the Individuals Present panel, select from one of the Contact Type options. Select one of the following in the Individuals present section: Individual not present Individual present Select Others present and enter the details in the Support Resources section. In the Support Resources section, record the client's closest friends and relatives. To add the support resources data in the grid, click Add. To change the grid view, select All or Active. The Effective and End dates determine if a resource is Active. Parent topic: BH - Contact Note Template Parent topic: BH - Psychopharm Template Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)

NextGen® Adaptive Content Engine Help Enterprise 8

Record Individuals Present

Open the BH - Individual Counsel/Psych Prog Note template. In the Individuals Present panel, select from one of the options for the Modality. Modality is only available on the Progress Note tab. In the Individuals Present section, select one of the following set of values: Individual not present and a Reason Individual present and a Contact Type If applicable, place a check mark next to Others present and type in the person's name and/or relationship in the field when it becomes available. The Support Resources section is where information about the client's closest friends and relatives are recorded. To enter a new person under Support Resources, fill in the fields in this section (First name and the Effective date are required) and click the Add button. The Effective and End dates determine if a resource is Active. To set the grid view, select one of the resource filters: Active All Parent topic: BH - Individual Counsel/Psych Prog Note Template

NextGen Behavioral Health Suite Help 5.5

Document the Assessment and Billing 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. Select Assessment/Reassessment Billing (BH), and then select OK. 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 during the assessment. In the Treatment Recommendations/Assessed Needs panel, document the recommended treatments and the patient's needs. Document the patient's assessment and diagnosis details. Document the applicable signatures from the tasking supervisor or staff. In the Time Entry Navigation sidebar