Record the Client's Presenting Concerns

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

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 Mental Status Exam Information

For a more comprehensive record than is offered on the Mental Status Evaluation panel, click the Mental Status Exam link. Mental Status Evaluation The BH - Mental Status Exam template opens. Note: The determination to perform a full exam should be made by the provider. Alternatively or in addition, a mental status narrative, including the client's appearance, mood, affect, speech, thought process/content, cognition, and insight/judgment can be entered in the Written narrative field. Parent topic: BH - Brief Assessment Template

NextGen® Adaptive Content Engine Help Enterprise 8

Record the Client's Presenting Concerns

Use the client's words to document the symptoms and presenting issues in the Presenting Concerns panel. In the Presenting Concerns panel of the BH CA Presenting Concerns template, enter an explanation for this visit to the office in the Reason for referral field. Click the My Phrases link to select a sentence to enter in the Reason for referral field. For more information on My Phrases, go to NextGen Healthcare Success Community and download the latest Getting Started User Guide for NextGen® Adaptive Content Engine. Parent topic: Intake Process for Comprehensive Assessment

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Presenting Concerns

Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Comp Assess - Concerns, and then select OK. Document whether the assessment is the initial assessment or an annual update to an existing assessment. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Presenting Concerns panel, enter the details of the patient's current concerns and the required help. Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Psychiatric Evaluation Presenting Concerns

The Presenting Concerns panel enables you to document the symptoms and presenting issues, in the client's own words, which prompted a visit to the office in the Reason for referral field. In the Presenting Concerns panel select No or Yes to answer the question: Comprehensive Assessment has been completed. If Yes, enter the date of the most recent assessment into the field. In the Reason for referral and chief complaint field, click to enter or dictate notable symptoms, presenting problems, behavioral and functional needs, etc. Enter Family/guardian description of problem. For History of present psychiatric illness, do one of the following actions: Select None reported. Enter or dictate history details. Parent topic: BH - Psychiatric Evaluation

Record the Client's Presenting Concerns

Recommendations

Record a Risk Assessment

Enter Assessment and Diagnosis Details

Record Mental Status Exam Information

Record the Client's Presenting Concerns

Document the Patient's Presenting Concerns

Enter Psychiatric Evaluation Presenting Concerns