Intake Visits for Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

Screening and Admission Visit Workflow

The BH - Screening/Admission Note template is used to document information that a program or Emergency Room might need for their initial evaluation of a client. Information gathered here is the basis for a summarization of the services and possible interventions that are initially provided to the client. Generally, this is completed by the non-clinical staff at the practice and can be done separately from a Comprehensive Assessment exam. The BH - Screening/Admission Note template can be accessed at any time during an encounter by selecting Other Templates from the bottom section of the navigation bar. Document Admission Data Document Referral Source Enter Assessment and Diagnosis Details Add Additional Notes Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

Individual Visit Workflows for Behavioral Health

Individual visit workflows for Behavioral Health enable the documentation of assessment and treatment plans for the individual client and are associated with the following Visit Types: Home Visit Psychiatric Diagnostic Evaluation Psychiatric Diagnostic Evaluation with Medical Services Psychotherapy - Individual Psychotherapy - Individual with E&M Virtual Visit Telephone Virtual Visit Video You can record new issues for the client on the Individualized Action Plan (IAP) template. The Comp Assess tab can be used to access the Treatment Recommendations/Assessed Needs panel. The IAP tab is used for the initial documentation of the client's goals, objectives and interventions for the assessed needs. The BH - IAP Review/Revision template is for updating any previously entered action plan elements. The BH - Relapse Prevention Plan template (Relapse Prev tab) is available from all of the individual psychotherapy visits. BH - Contact Note Template The BH - IAP Review/Revision Template BH - Indi

NextGen® Adaptive Content Engine Help Enterprise 8

Document Encounters for Behavioral Health Visits

You can use the NextGen® Adaptive Content Engine to document Behavioral Health encounters in the following workflow groupings: Residential Service Intake Individual Therapy Group Therapy Medication Management Crisis Management Screening or Admissions Transfer or Discharge Optimize Usage of Behavioral Health Templates Parent topic: Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

BH - Individualized Action Plan (IAP) Template

The Individualized Action Plan (IAP) template is the master treatment plan of care for the client. Following the Comprehensive Assessment exam, the Behavioral Health provider may choose to initiate an IAP. The IAP is completed in collaboration with the Behavioral Health client and a copy of the finished plan is usually signed by the client. The action plan template enables users to leverage electronic functionality by tying together the data across the client’s assessment, IAP, and Progress Note. Because this information is shared, the user is not repeatedly entering the same data. Visit Types for Individualized Action Plan Complete the IAP General Panel Document Assessed Needs, Goals, Objectives and Interventions Enter Goal Information Record Objective Information Document Interventions, Methods, and Actions Other Functional Areas Not Applicable/Methadone Treatment Transition/Discharge Criteria Panel Enter Document Signatures Parent topic: Intake Visits for Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

BH - Brief Assessment Template

The BH- Brief Assessment template enables providers, case workers and social workers, to document on an abridged version of the Comprehensive Assessment template set. Because a comprehensive exam takes a significant amount of time (more than a single client visit), the BH - Brief Assessment template can be used to complete the evaluation during one encounter. Start a New Intake for a Brief Assessment Record the Client's Presenting Concerns Brief Assess Histories Panel Record Substance Use and Addictive Behavior Histories Enter Tobacco Usage Add Trauma History on the Brief Assess Record Mental Status Exam Information Record a Risk Assessment Enter Assessment and Diagnosis Details Enter Treatment Plan Information Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Intake Visits for Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

Comprehensive Assessment Template Set

The workflow of a comprehensive assessment is a set of five templates that enable you to perform a complete intake evaluation for either an adult or pediatric, Behavioral Health clients. The comprehensive assessment is meant to be completed by a clinician designated by the practice. This occurs during the agency’s intake process. From the Comp Assess tab is also known as the BH CA Presenting Concerns template. The following templates that make up the Comprehensive Assessment Template set are accessed through a section tab menu: Concerns Social Hx Bh Hx Functional Assess/Plan Visit Types for Comprehensive Assessment Access the BH CA Presenting Concerns Template Intake Process for Comprehensive Assessment Social Hx of a Comprehensive Assessment BH Hx Section Tab Overview Explanation of the Functional Section Tab Assess/Plan Section Tab Parent topic: Intake Visits for Behavioral Health