Record the Client's Presenting Concerns

NextGen® Adaptive Content Engine Help Enterprise 8

Start a New Intake

To start document a new episode of care, click the New Intake button in the General panel of the BH CA Presenting Concerns template. CAUTION: The New Intake button is used if this documentation represents a new problem or the recurrence of an old problem. When selected, a confirmation window states that you are about to clear data. Selecting Yes indicates that you are beginning a new episode of care. The historical data still exists in the past encounters. In the Program name field, click to select a value. Note: Program names can be added and/or edited by the practice on the Custom Picklists, system template. Entering a Program name helps when setting up reports for the practice but is not required. Enter the current time in the Start field by clicking the clock button. The Start and End buttons are available here and at the bottom of the last section tab (Assess/Plan) in the Comprehensive Assessment set of templates. The values documented in either place are immediately reflected in

NextGen® Adaptive Content Engine Help Enterprise 8

Record the Client's Presenting Concerns

On the Presenting Concerns panel, do one of the following actions in the Written HPI narrative field: Use the client's words to document the symptoms and presenting issues that prompted a visit to the office. Use the My Phrases functionality. Click Add. Click Save & Close. Parent topic: BH - Brief Assessment Template

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

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

Access the BH CA Presenting Concerns Template

To complete a comprehensive assessment as part of the intake process, enter the following information on the Home Page - Behavioral Health template: In the Visit Type field, select a value from the picklist. Select Intake no Medical Services or any of the other Visit Types listed in the above section of this User Guide. Click the Comp Assess tab to launch the BH CA Presenting Concerns template. The Concerns section tab is highlighted to indicate that you are on the w template. The abbreviations presented in the name of the template refer to Behavioral Health (BH) and Comprehensive Assessment (CA). Parent topic: Comprehensive Assessment Template Set

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Intake Notes Using the Comprehensive Assessment Templates

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. Select the program, specialty, and visit type for the patient. Complete the assessment in the Concerns tab. Complete the assessment in the Social Hx tab. Complete the assessment in the BH Hx tab. Complete the assessment in the Asses/Plan tab. Select Generate Document. Document the Patient's Presenting Concerns You can document a patient's initial or annual assessment details and the presenting concerns. Document the Patient's Social Support Information You can document the patient's living situation, development history, and other social support details. Document the Patient's Mental Health and Risk Assessment Information You can document the patient's mental health history, substance use, and risk assessment using various screening tools. Document the Summary of the

Record the Client's Presenting Concerns

Recommendations

Start a New Intake

Record the Client's Presenting Concerns

Enter Psychiatric Evaluation Presenting Concerns

Document the Patient's Presenting Concerns

Access the BH CA Presenting Concerns Template

Document the Patient's Intake Notes Using the Comprehensive Assessment Templates

Start a New Intake

Record the Client's Presenting Concerns

Enter Psychiatric Evaluation Presenting Concerns

Document the Patient's Presenting Concerns

Access the BH CA Presenting Concerns Template

Document the Patient's Intake Notes Using the Comprehensive Assessment Templates