Enter Service Preferences for the Client
- Expand the Service Preferences panel.
- Type details in the Describe individual/family/guardian/significant other perception of needs and preferences for care, including environmental supports field.
Recommendations
NextGen® Adaptive Content Engine Help Enterprise 8
The Treatment Recommendations/Assessed Needs panel enables the delineation of assessed needs, their priority, their status, the date identified, the rationale for not addressing a particular need, and the date resolved. The priority, assessed need and status are required fields if this section is used. If no recommendations are indicated, select No additional recommendations clinically indicated. To enter an assessed need, click the Priority field to type a number. Free text an explanation in the Assessed Need field. In the Status field, select a value from the Need status list. Enter a date in the Identified field. If the need has been declined, deferred, or referred out, enter a Rationale. If the assessed need is resolved, enter the Resolved date. Enter other assessed needs if required. To manage existing assessments, highlight a row in the grid and click Update or Remove. To delete data from the related fields before it is saved to the grid, click Clear. Select any Further evaluatioEnter Treatment Recommendations
NextGen® Adaptive Content Engine Help Enterprise 8
On the Assess/Plan section tab expand the Life Goals, Strengths, Abilities and Barriers panel. Enter details for the following fields: Life Goals Strengths Abilities Barriers Barriers to care and existing gaps Past and present successes in achieving desired goals Parent topic: Assess/Plan Section TabEnter Life Goals, Strengths, Abilities and Barriers
NextGen® Adaptive Content Engine Help Enterprise 8
The Assess/Plan section tab for the Comprehensive Assessment template set enables you to document the client's life goals, strengths, service preferences, as well as the assessment and treatment recommendations for the client. The Assess/Plan section tab has six panels: Life Goals, Strengths, Abilities and Barriers Service Preferences Clinical Formulation/Interpretative Summary Assessment/Diagnosis Treatment Recommendations/Assessed Needs Signatures This template also includes the Start and End functionality along with the ability to print the Comprehensive Assessment note. Enter Life Goals, Strengths, Abilities and Barriers Enter Service Preferences for the Client Record Who Supplied the Clinical Data and Provide an Interpretive Summary Enter Assessment and Diagnosis Details Enter Treatment Recommendations Enter Document Signatures Parent topic: Comprehensive Assessment Template SetAssess/Plan Section Tab
NextGen Behavioral Health Suite Help 5.5
From the Treatment Recommendations/Assessed Needs panel, in the Further evaluations needed section, select the evaluations needed. Select None indicated if no other evaluations are needed. Document the Level of care/indicated service recommendations. Enter a value for Individual served/guardian/family response to recommendations. Parent topic: Enter Treatment Recommendations and Assessed NeedsEnter Further Evaluations Needed
NextGen® Adaptive Content Engine Help Enterprise 8
In the Plan and Additional Information panel, click My Plan to open the My Plan template set. My Plan Template Enter the details of an action plan that can be implemented by the client between sessions, in the Plan/additional information field. Parent topic: Nurse's Progress Note (Long) Parent topic: Nurse's Progress Note (Short)Enter Plan of Care and Additional Information
NextGen® Adaptive Content Engine Help Enterprise 8
In the Post Discharge Support Systems section, enter any known Family supports. Type any possible Community Supports. Recount the Agencies involved in the client's care in the associated field. Enter any Follow up information. Parent topic: Enter Transfer/Discharge Data