NextGen Knowledge Center

Enter DSM IV Assessment Details

  1. In the Assessment/Diagnosis panel, click the DSM IV link to open the BH - DSM IV template.
  2. In the Axis I & II section, click the Copy Forward button to pull in previously entered assessment/diagnosis.
  3. To open the Common assessment template, click Add Common Assessment.
  4. To document information for any person who should be contacted concerning this client, click Mandated Care Coordination.
  5. To enter a new diagnosis, click Add to open the Add or Update Assessment template.
  6. After a diagnosis has been entered, click Save & Close to return to the BH - DSM IV template.
  7. Do one of the following in the Axis III section:
    • In the first available Diagnoses field, click to launch the diagnosis search window. Since the exact code for the client’s non-behavioral health diagnosis may not be apparent, you may not be able to select an Axis III diagnosis code.
    • If available, select a code that was previously entered from the search window under Patient Diagnosis.
    • If there is no appropriate code under Patient Diagnosis, close the diagnosis search window, and then click the first available Reported by patient field. A list of common diagnoses opens for selection of a value.
    • Alternatively, the list may be closed, and a diagnosis manually typed in the field.
    • Click Copy Forward to populate all of the previously entered diagnoses.
  8. The first time an Axis III diagnosis is entered on a client's chart, click the corresponding Add to Dx Module button to include that code in the client’s diagnosis history and add it to the Problems module.
  9. Use the Reported by patient field to select any relevant information from the list.
  10. In the Axis IV section, select a value to indicate the severity of psychosocial and environmental problems.
  11. Select No or Yes for any relevant items in the Problems related to section.
  12. If Yes is selected for any of the above values, enter details in the associated field as needed.
  13. Under Axis V, the Current GAF and Highest GAF in past year click either field to enter a new value.
    These fields may be populated with previously entered values. The Axis V section enables you to enter a Global Assessment of Functioning score.
  14. To review descriptions of how the GAF score is calculated, click the GAF Scale link, and enter a number in the Current GAF field.
    When a number is entered, the date of today’s encounter fills the corresponding date field.