Record Mental Status Exam Information

NextGen® Adaptive Content Engine Help Enterprise 8

Record Substance Use and Addictive Behavior Histories

On the Substance Use/Addictive Behavior History panel, select the None reported check box if the client denies substance use or addictive behavior. Select one or more of the addictions options reported by the client. If needed, Other can be selected to type an historical issue that is not available on the panel in the associated field. Select the client's response for Drinks alcohol. If no information has been entered for the client's tobacco use history elsewhere, the read-only field is blank; to enter this data, click the Tobacco Usage link. If any of the addiction options apply, click the Substance Use link available at the top, right of the panel to gather more details. The BH Substance Use Assessment template opens. Enter Tobacco Usage Parent topic: BH - Brief Assessment Template Parent topic: BH - Psychiatric Evaluation

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

NextGen® Adaptive Content Engine Help Enterprise 8

Record Substance Use and Addictive Behavior Histories

On the Substance Use/Addictive Behavior History panel, select the None reported check box if the client denies substance use or addictive behavior. Select one or more of the addictions options reported by the client. Use the Other field can be selected to type an historical issue that is not available on the panel in the associated field. Select the client's response for Drinks alcohol. Click the Tobacco Usage link to enter the client's tobacco use. If any of the addiction options apply and a more in-depth evaluation is required, click the Substance Use link to enter more details. The BH Substance Use Assessment template launches. Enter Tobacco Usage Parent topic: BH Hx Section Tab Overview

NextGen® Adaptive Content Engine Help Enterprise 8

Substance Use Assessment Exam

BH Substance Use Assessment is a template on which a clinician or nurse can gather information about a client’s substance use history and how an addiction might negatively impact the client’s life. The information gathered on this template is configured to appear on whatever document is generated. It is one of just a few templates that launches with all but the top panel collapsed. This was done to make it easier find and use the appropriate panel. The recommended workflow is to expand a panel to document the information and collapse it when that section is complete. This template is launched from a Substance use link found on the Substance Use/Addictive Behavior panel. This link is also available on many templates throughout the Behavioral Health template set. Enter Chemical Use/Abuse History Add Substance Use Data Document Tobacco Use on the Substance Use Assessment Exam Add Gambling Information Document Impact of Substance Use/Addictive Behaviors of Life Areas Enter Toxicology Scree

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

Record Mental Status Exam Information

Recommendations

Record Substance Use and Addictive Behavior Histories

Update the Client's Current Assessment

Record Substance Use and Addictive Behavior Histories

Substance Use Assessment Exam

Enter Assessment and Diagnosis Details

Record a Risk Assessment

Record Substance Use and Addictive Behavior Histories

Update the Client's Current Assessment

Record Substance Use and Addictive Behavior Histories

Substance Use Assessment Exam

Enter Assessment and Diagnosis Details

Record a Risk Assessment