Enter Counseling Details

You can enter the counseling details for a patient and include them in the visit note.

1. Open NextGen® Enterprise EHR.
2. For a patient record, open a new encounter.
3. Open the Finalize template.
4. On Evaluation and Management Coding, select the Counseling Details link.
   The Counseling Details template opens.

   

5. In the Counseling/Educational Details section, do the following:
   1. Select the counseling type, method, and evaluation.
      The counselor's name and date appear.
   2. Enter the time spent in patient counseling.
   3. Enter additional counseling information.
   4. Enter the type of educational materials the patient received.
   5. To enter details about an interpreter, select the corresponding check box, and then enter their language, name, and relationship with the patient.
   You can enter details for up to five types of counseling and education. Total counseling time (minutes) displays the sum of the total time entered for counseling sessions you entered.
6. To indicate which counseling and educational factors appear in the visit note, do one of the following:
   • To include all the information you have entered, select Detailed document.
   • To include only a statement that you have reviewed the counseling and educational factors, select Reviewed.
7. In the Counseling/Educational Factors section, do the following:
   1. Select the Readiness to learn check boxes that reflect the patient's attitude toward learning.
   2. Select the Barriers to learning check boxes for barriers the patient has toward learning.
   3. To document that an interpreter is needed, select the corresponding check box and then enter the patient's preferred language.
   4. Select the patient's preferred learning methods.
   5. Enter information about the patient's cultural and spiritual needs.
   6. To edit the patient's marital status, select the field and select the status.
   7. Enter the patient's race.
      Note: The Religion field is read-only and displays the religion from the patient's demographic information.
8. Select Save & Close.