Enter the Prescriber's Evaluation

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

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

NextGen® Adaptive Content Engine Help Enterprise 8

Document Medication Information

On the BH - Psychopharm template, expand the Medication Information panel. Answer the following questions with Yes, No, or Not applicable as applies: Takes meds as prescribed Changes in medical status Other meds Allergic reactions Side effects reported Note: All allergic reactions must be entered in the Allergies module to ensure that they are apparent on future visits. Click the Side effects reported link to open the Medication Side Effects - BH template. Entering information on the template automatically selects the Yes option in the Medication Information panel and turns the Side effects reported link purple to indicate that data is present from that link. At the top of the grid, click the Comments link if additional information is required. All prescriptions currently existing in the Medications module are visible in the grid under the Active Medications section. If a medication is Inactive, a stop date appears in the grid. Under Active Medications, double click in the grid to laun

NextGen® Adaptive Content Engine Help Enterprise 8

BH - Psychopharm Template

The BH - Psychopharm template is intended for the Behavioral Health prescriber to document a follow-up visit. The interventions can be tied to the client's treatment plan, but the content is specific to the needs of psychiatric professionals who prescribe medication. Access the BH - Psychopharm Template Enter Program Information Record Vital Signs for the Nurse Progress Note Document Individuals Present Record Mental Status Exam Information Enter the Prescriber's Evaluation Record a Risk Assessment Document Medication Information Enter Assessment and Diagnosis Details Enter Goals, Objectives, and Interventions Addressed Today Record Plan Details Enter Document Signatures Parent topic: Behavioral Health Medication Management

NextGen® Adaptive Content Engine Help Enterprise 8

BH - Psychiatric Evaluation

The Psychiatry Eval tab is designed to be a stand-alone template for a psychiatrist, nurse practitioner (NPP), or other Behavioral Health professional who is qualified to conduct and document an initial psychiatric assessment of the client. The information on the Psychiatry Eval tab overlaps with the data recorded on the Comp Assess tab. Of the 17 panels on the tab, only two (Physical Health History and Issues for Children/Adolescents) are not identical to the corresponding panels on the Comprehensive Assessment. If a Comprehensive Assessment was completed for this client prior to the Psychiatric Evaluation, much of the information is filled. It is important to note that medications can be prescribed during the psychiatric evaluation. The Behavioral health billing section is available at the bottom of the Psychiatry Eval and Progress Note tabs to submit billing codes. Some providers may want to use the SOAP tab to document additional elements of the physical exam. For more information

NextGen® Adaptive Content Engine Help Enterprise 8

Update the Client's Current Assessment

The Current Assessment panel provides quick entry of whether there has been a change or no change in the client’s condition. There are buttons to indicate the client’s progress or lack of progress. Navigate to the Current Assessment panel and select one of the statuses for Individual’s progress. Complete the Individual’s report of progress towards goals/objective since last session field. Enter No significant change or Notable change and if notable is selected, list the changes in individual’s condition field for the following: Mood/affect Thought process/orientation Motor activity and speech Behavior/functioning Medical condition Substance use/addictive behaviors If there has been any change in these areas, enter information about the change into the respective field or select Not applicable. To complete a full Substance Assessment, click on the Substance Use link to launch the BH Substance Use Assessment template. To document a comprehensive exam for the client’s current mental statu

Enter the Prescriber's Evaluation

Recommendations

Enter Assessment and Diagnosis Details

Enter Goals, Objectives, and Interventions Addressed Today

Document Medication Information

BH - Psychopharm Template

BH - Psychiatric Evaluation

Update the Client's Current Assessment

Enter Assessment and Diagnosis Details

Enter Goals, Objectives, and Interventions Addressed Today

Document Medication Information

BH - Psychopharm Template

BH - Psychiatric Evaluation

Update the Client's Current Assessment