Enter Assessment and Diagnosis Details

NextGen® Adaptive Content Engine Help Enterprise 8

Enable the DSM IV Link

To document using the DSM IV standards, you must first set up the DSM IV link to appear on the Assessment/Diagnosis panel. The DSM IV link can be enabled on the Practice Configuration or the Documentation Configuration practice templates. You do not need to apply this setting on both templates. The settings applied on either template are shared and do not need to be repeated. Select the File menu and click System/Practice Template. Click the Practice tab and set Show to All. Select one of the following: Practice Configuration Documentation Configuration Scroll down to the Behavioral Health section. Under DSM IV/DSM-5 Assessment/Diagnosis Template Display Options, select the Show DSM IV link option. Click Save and Close at the top right. Enter DSM IV Assessment Details The BH - DSM IV template is used to document DSM IV assessments. Data previously entered on the Assessment/Diagnosis panel appears on this template for the current encounter. Parent topic: DSM IV Configuration

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Severity Descriptions in File Maintenance

The Severity picklist packaged with the system does not include Extreme or Persistent, which are required to meet DSM-5 standards. These values can be added to the master list in File Maintenance. From the Master Files - System list, select Diagnosis Severities. The Diagnosis Severities List window launches. Click the Open Menu button to select New. The Add Diagnosis Severity Information window appears. Type Extreme in the Description field. Enter a Note to explain the additional list item if required. Click Next to clear the window for another entry. Add Persistent. Click OK to save the new values and return to the Diagnosis Severities List window. Click Close. Parent topic: Practice Configuration Options for Behavioral Health

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

Update the Client's Current Assessment

The Current Assessment panel provides quick entry of whether there has been a change or no change in the client’s condition. There are buttons to indicate the client’s progress or lack of progress. Navigate to the Current Assessment panel and select one of the statuses for Individual’s progress. Complete the Individual’s report of progress towards goals/objective since last session field. Enter No significant change or Notable change and if notable is selected, list the changes in individual’s condition field for the following: Mood/affect Thought process/orientation Motor activity and speech Behavior/functioning Medical condition Substance use/addictive behaviors If there has been any change in these areas, enter information about the change into the respective field or select Not applicable. To complete a full Substance Assessment, click on the Substance Use link to launch the BH Substance Use Assessment template. To document a comprehensive exam for the client’s current mental statu

NextGen® Adaptive Content Engine Help Enterprise 8

Complete the Diagnoses Section for Transfer/Discharge

In the Behavioral Health Diagnoses section, select any of the available links: Diagnosis Code Lookup Add Common Assessment Mandated Care Coordination In the required Diagnostic description field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. In the Status field, click to select a value from the list. If appropriate, enter a Severity. If needed, enter a Differential dx, and/or Impression. To enter Specifiers, click one of the following: In the field to manually enter any required values The My Phrases link. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. For chronic conditions, select the option to Mark diagnosis as chronic. Select the options to add the assessment to the Clinical problems, My tracked problems, and/or My favorites where applicable. Click Add To Grid. In the Physical Hea

NextGen® Adaptive Content Engine Help Enterprise 8

Behavioral Health Common Assessment Page

The BH Assessment page that opens in the Add Common Assessment template includes the following updates for DSM-5: When the Practice Configuration practice template option to display a link for the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM IV) is not selected, the Add Common Assessment template for Behavioral Health displays an updated grid and picklist (replacing the required, DSM IV, Axes lists). The Status picklist is not required. Users can cancel out of the list without making a selection. The picklist includes the following selections: Mild Moderate Severe Persistent Extreme The grid in the DSM-5 section includes the following headers: # Dx (Code) Status Severity Impression/Differential Dx Specifier The system is packaged with existing, common assessment, diagnosis code data formatted to appear on the Common Assessment template. If no data is preloaded for a common assessment set in the package, launching that common assessment page returns the foll

Enter Assessment and Diagnosis Details

Recommendations

Enable the DSM IV Link

Enter Severity Descriptions in File Maintenance

Record a Risk Assessment

Update the Client's Current Assessment

Complete the Diagnoses Section for Transfer/Discharge

Behavioral Health Common Assessment Page

Enable the DSM IV Link

Enter Severity Descriptions in File Maintenance

Record a Risk Assessment

Update the Client's Current Assessment

Complete the Diagnoses Section for Transfer/Discharge

Behavioral Health Common Assessment Page