Enter Goals, Objectives and Interventions Addressed Today

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

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

Enter Goals, Objectives and Interventions Addressed Today

Goals and/or objectives that were entered previously on the Comprehensive Assessment templates populate in this panel. The grid on this panel offers a quick view of the client's current goals and objectives. In the Goals/Objectives Addressed As Per Individualized Action Plan section, Goal today field, click to select a previously entered item. Select the Objective today from the list previously entered objectives. Click Add. In the Interventions Addressed Today section, click Select From Previous IAP Intervention to choose a previous entered value. Enter the Interventions/methods provided. Record the Response to Interventions/progress toward goals and objectives. Document the Issues referred to physician/psychiatrist for consideration. Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Goals/Objectives and Interventions Addressed Today

Expand the Goals/Objectives and Interventions Addressed Today panel. Click the Goal today field to select a goal from a list of previously entered goals. A goal must be entered before an objective can be selected. Select the Objective today from the picklist. Click the Add button. In the Interventions Addressed Today section, do one or both of the following: Click the Select From Previous IAP Interventions link to choose a value previously entered for the client. Click Select Other Interventions to open a practice-wide list of interventions. Each selected intervention appears in the Intervention/method provided field. Add additional details by typing in the Intervention/method provided field. Enter the Response to Interventions/progress toward goals and objectives. Parent topic: BH - Contact Note Template

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Goal Information

When populating data in the Goal Information panel, it is important to note that need and intervention data is not mandatory to complete the plan, but, goals are required. Assessed needs can also be entered on the Comprehensive Assessment template, on the Assess/Plan tab, Treatment Recommendations/Assessed Needs panel, during the intake process. In the Goal Information panel, click the Linked to assessed need field to highlight a value in the resulting list and then click OK. The read-only From form dated and Need source fields pull from information entered during the Comprehensive Assessment exam. In the Functional area field, click to select a value from the list. In the Goal field, select an item that is associated with the assessed need or manually type a goal. Set the Start date and a Target completion date for the goal. If the start and target dates are not entered before selecting an Adjusted target date, the system throws an alert. Set an Adjusted target date and fill in the va

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Goals, Objectives, and Interventions Addressed Today

In the Goals/Objectives Addressed as Per Individualized Action Plan section, click the Goal today field to select an item. Select the Objective today from the list. Click Add. Select the appropriate Stage of treatment. In the Therapeutic Interventions Delivered in Session section, select any option that applies under Describe interventions. Enter information in the Comment on all interventions selected field. Under Counseling provided with client/family/caregiver, select from the following topics: Diagnostic results/impressions and/or recommended studies Instruction for management/treatment and/or follow-up Importance of compliance with chosen treatment Client/family/caregiver education Risks and benefits of treatment options Prognosis Risk factor reduction Enter details for each selection in the Comments field. Document the Response to intervention/progress toward goals and objectives. Type details for each selection in the Comments field. Under Coordination of care provided, set the