Document Intervention

You can document assessment, intervention, and patient education plan in the Brief Intervention panel of the SBIRT Screening template. You can also indicate if education is provided to the patient, family, or caregiver.

1. Open NextGen® Enterprise EHR.
2. In the navigation bar, select Screening Tools.
   The Screening Tools template opens.
3. In the Screening Tools Available section, select Screening, Brief Intervention, and Referral to Treatment (SBIRT).
   The SBIRT Screening template opens.

   

4. Expand the Brief Intervention panel.
   

5. Enter an assessment and a diagnosis status.
   Note: If you document details in the SBIRT Impression/Risk section in the Screening panel, NextGen® Enterprise EHR automatically fills Encounter for Screening, unspecified and Z13.9 in the Select Assessment and Code fields respectively. You can change the Select Assessment and Code values, if needed.
6. To enter predefined intervention details, select the My Phrases link or enter details.
7. To document treatment plan for the patient, select the My Plan link.
8. Select the answer for Education provided to patient/family/caregiver?.
9. To enter the predefined education material discussed details with the patient, select the My Phrases link or enter the details.
10. To view, add, or edit the list of education documents for patient, select Patient Education.
11. To add follow-up and disposition for the patient, select Follow Up.
12. Save and close the template.