Record Substance Use and Addictive Behavior Histories

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

Record Mental Status Exam Information

To record information on the Mental Status Exam panel, record a response to the question Does the individual require a full Mental Status Exam? Select Yes for a comprehensive record and click the Mental Status Exam link. Select the No if a full status exam is not necessary. Note: It is up to the provider to determine if a full mental status exam is required. Indicate whether there has been No significant change or No notable change in the following areas and type any notable change in the adjacent fields: Mood/affect Thought process/orientation Motor activity and speech Behavior/functioning Medical condition Substance use/addictive behavior Select the Not applicable check box if substance use or addictive behaviors do not apply to this client. Click the Substance Use link to open the BH Substance Use Assessment template. Parent topic: BH - Psychopharm Template

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

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 Tobacco Usage

The client's current smoking status must be recorded to meet Quality Reporting requirements. The Social History - Tobacco template in the Behavioral Health template set only includes the Tobacco option as the other social history data is documented in different sections of the template set. This ensures that users are documenting the required data and prevents duplicate information from printing in the documents. In the Substance Use/Addictive Behavior History panel, click the Tobacco Usage link. Select one of the following options for Have you ever used tobacco?: No/never Yes Unknown If you select No/never or Unknown, click Save & Close to return to your previous workflow. Select Yes or No for Have you used tobacco in the last 30 days? Select Yes or No for Have you used smokeless tobacco products in the last 30 days? Note: For the current encounter, if you select No\Never for Have you ever used tobacco?, the system selects No for both questions. If you have selected No/Never in the pr

NextGen® Adaptive Content Engine Help Enterprise 8

Document Mental Health and Addiction Treatment Service Histories

On the Mental Health and Addiction Treatment Service History panel, do one of the following: Place a check mark for None reported. In the Treatment services history within the past five years section, enter as much information acquired from the client in the fields. Type of service is the only required field in this section. Click Add. In the Outpatient section, select Not applicable or enter the Age at time of initially seeking outpatient treatment services. Enter the Total number of lifetime outpatient treatment experiences. In the Inpatient section, select Not applicable or enter the Age at time of initial inpatient treatment. Click the Total number of lifetime inpatient treatment experiences field to enter a value. In the Er/detox section, select Not applicable or enter the Total number of er visits in the last 6 months. Enter the Number of non detox hospital days in the past 6 months and select a reason. Medical Psychiatric Both Click the Number of days the client has been in drug

Record Substance Use and Addictive Behavior Histories

Recommendations

Record Substance Use and Addictive Behavior Histories

Record Mental Status Exam Information

Update the Client's Current Assessment

Substance Use Assessment Exam

Enter Tobacco Usage

Document Mental Health and Addiction Treatment Service Histories