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

Document Individuals Present

In the Individuals Present panel, select from one of the Contact Type options. Select one of the following in the Individuals present section: Individual not present Individual present Select Others present and enter the details in the Support Resources section. In the Support Resources section, record the client's closest friends and relatives. To add the support resources data in the grid, click Add. To change the grid view, select All or Active. The Effective and End dates determine if a resource is Active. Parent topic: BH - Contact Note Template Parent topic: BH - Psychopharm Template Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)

NextGen® Adaptive Content Engine Help Enterprise 8

Record Plan Details

On the BH - Psychopharm template, navigate to the Plan panel. Document the Diagnosis since the last visit by selecting from the following: No change Yes, CA update required Next to Rationale for changing medications, select Not indicated or enter an explanation in the associated field. Answer No or Yes to: Were Medications delivered today. Next to If Yes, for what duration select one of the following options: Weekly Monthly Other Select No or Yes to indicate if there was a Prescription written. Document if the medication was Called into pharmacy. Next to Lab tests were ordered, select No or Yes. If Yes, enter available Results in the associated field Click the Review Labs link to open the Orders module and to view existing lab orders for this client. Document Instructions/comments/plan, as applicable. To schedule a follow up, click the Follow Up button to the right of Next Appointment. Follow-up/Disposition The Follow-up/Disposition template opens to document appointment details. Paren

NextGen® Adaptive Content Engine Help Enterprise 8

Enter the Prescriber's Evaluation

Expand the Prescriber's Evaluation panel. If there are no modifications, select the No changes reported/observed check box. In the Interim Update field, use the My Phrases link or manually type information about the client's progress since the last visit related to symptoms, effectiveness of medications, substance use, changes in family/social history, overall functioning, and any new issues. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide forNextGen®Adaptive Content Engine. Parent topic: BH - Psychopharm Template

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Goals, Objectives and Interventions Addressed Today

Any goals and/or objective data that were previously entered on the Comprehensive Assessment template set populate in the panels found here. 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, field, click to Goal today select a previously entered item. Select an Objective today from the picklist of previously entered objectives. Click Add. In the Interventions Addressed Today section, do one or both of the following actions: Click Select From Previous IAP Intervention to select a previously entered value. Enter details in the Interventions/methods provided memo field. Click the My Phrases link to select a sentence to enter in the Interventions addressed today section. Click Add. Click Save & Close. Enter the Response to Interventions/progress toward goals and objectives. Parent topic: BH - Individual Counsel/Psych Prog Note Template Parent topic: Group Visits for Behaviora

Enter Goals, Objectives, and Interventions Addressed Today

Recommendations

Enter Assessment and Diagnosis Details

Record a Risk Assessment

Document Individuals Present

Record Plan Details

Enter the Prescriber's Evaluation

Enter Goals, Objectives and Interventions Addressed Today

Enter Assessment and Diagnosis Details

Record a Risk Assessment

Document Individuals Present

Record Plan Details

Enter the Prescriber's Evaluation

Enter Goals, Objectives and Interventions Addressed Today