Document Treatment Recommendations/Assessed Needs

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 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 Treatment Recommendations

The Treatment Recommendations/Assessed Needs panel enables the delineation of assessed needs, their priority, their status, the date identified, the rationale for not addressing a particular need, and the date resolved. The priority, assessed need and status are required fields if this section is used. If no recommendations are indicated, select No additional recommendations clinically indicated. To enter an assessed need, click the Priority field to type a number. Free text an explanation in the Assessed Need field. In the Status field, select a value from the Need status list. Enter a date in the Identified field. If the need has been declined, deferred, or referred out, enter a Rationale. If the assessed need is resolved, enter the Resolved date. Enter other assessed needs if required. To manage existing assessments, highlight a row in the grid and click Update or Remove. To delete data from the related fields before it is saved to the grid, click Clear. Select any Further evaluatio

NextGen® Adaptive Content Engine Help Enterprise 8

Document Assessed Needs, Goals, Objectives and Interventions

Any previously entered data fills the grid under the Assessed needs section on the panel. On the Assessed Needs, Goals, Objectives and Interventions Overview panel, click the Display status of field and select a value to sort the grid. Click the Add button beneath the grid to enter an Assessed need on the template. In the Priority field, click to type a number. Type an explanation in the Assessed Need field. In the Status field, select a value from the Need status to display list. Enter a date in the Identified field. If applicable, set the Resolved date. If the need has been declined, deferred, or referred out, enter a Rationale. Click Save. Do one of the following: Click Clear for Add to enter other assessed needs. Click Close to return to the IAP tab. Edit an Assessed Need Manage Data in the Assessed Needs, Goals, Objectives and Interventions Grid Parent topic: BH - Individualized Action Plan (IAP) Template Parent topic: The BH - IAP Review/Revision Template

NextGen® Adaptive Content Engine Help Enterprise 8

Add a New Goal for IAP Reviews

When entering data in the Goals and Objectives Status Section panel, it is important to note that needs and interventions are not mandatory to complete the plan, but goals are required. The grid at the bottom of this panel offers a quick view of the client’s current needs, goals, and objectives. In the Goals and Objectives Status Section panel, select the New Goal link to open the BH- New Goal template. BH-New Goal Select a previously entered need for Linked to assessed need and click OK. In the Functional area field, select from the list. Type a new Goal and enter the Start date and Target completion date. Note: If the start and target dates are not entered before selecting an Adjusted target date, the system alerts the user to enter them. Enter the Desired outcomes for assessed need in individual's words. Record the Supports, resources, organizations and individuals needed to meet this goal. Answer No, Yes, or Yes, but deferred to the question: Has a problem been identified and enter

NextGen Behavioral Health Suite Help 5.5

Enter Treatment Recommendations and Assessed Needs

In the Treatment Recommendations/Assessed Needs panel, select the priority by selecting Priority. Enter the Assessed need. Select Status to select from the list. Enter date Identified. Enter the Rationale. Select Add. The information is added to the grid. Treatment Recommendations/Assessed Needs panel Enter Further Evaluations Needed Treatment Planning Updates Parent topic: Document the Assessment and Billing Information