Document Issues for Children/Adolescents
Expand the
Issues for Children/Adolescents
panel.
Record the answers to the following issues for children/adolescents:
Wish list
Worry list
Ambitions
What makes you happy
What makes you sad
To whom do you go to when you are sad or worried
Other
Recommendations
Explore
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 values. In the Individuals Present section, do on of the following: Select Individual not present and a Reason. Select Individual present. Select Others present and document their names. Enter the client's closest friends and relatives in the Support Resources section and click Add. Note: The First name and the Effective date are required To set the filter, click Active to view just the current resources or click All to see every resource ever associated with this client. Parent topic: BH - Psychiatric Evaluation
NextGen® Adaptive Content Engine Help Enterprise 8
Enter Developmental History Information
All of the data in the Development History panel carry forward data from encounter to encounter for ease of documentation. Navigate to the Development History panel. Select from one of the links at the top of the panel: Developmental Milestones - document Child Developmental Record (data shares from the Pediatrics template set) and/or Child Development History (information can be free-typed). M-CHAT and PSC developmental screenings (described below) can also be recorded on the Child Development Record template Modified Checklist for Autism in Toddlers (M-CHAT) - enter data and calculate a score (same template that is available from the Developmental Milestones link) Robins, D.L., Fein, D., & Barton, M. (2009). The Modified Checklist for Autism in Toddlers, Revised, with Follow-up (M-CHAT-R/F). Self-published. Pediatric Symptom Checklist (PSC) to enter data and calculate a score (same template available from the Developmental Milestones link) Bright Futures Resource and Tool Kit ©2010 -
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
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
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)
