Save the Documented Assessment Details

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Assessment Plan Details

Open NextGen® Enterprise EHR. On the Assessment Plan Details template, select the A/P Details tab. To add or change a diagnosis in the Today’s Assessments grid, select Add or Edit to open the Add or Update Assessment template. To change the current working assessment, in the Today's Assessments grid, select the diagnosis being addressed for this encounter. The selected diagnosis appears in the Selected Dx field. It becomes the new working assessment that carries forward to the other templates that share the assessment. Enter details manually or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections. To enter follow-up appointment and disposition information, select Follow Up. To document counseling educational details and factors, select the Counseling Details link. To enter post-operative details, select the Postoperative Quality Reporting link. For more information on the associated quality measure, selec

NextGen® Adaptive Content Engine Help Enterprise 8

Open the Assessment / Plan Details Template

Some specialties (for example, Cardiology) access the Assessment Plan Details template differently. For more information, go to NextGen Healthcare Success Community, and download the latest specialty guide of NextGen® Adaptive Content Engine for instructions if the following does not apply: Open NextGen® Enterprise EHR. Open the SOAP template. In Assessment / Plan, select A/P Details in the navigation bar. The Assessment Plan Details template opens. Assessment Plan Details Enter Assessment Plan Details You can enter comments, differential diagnoses, and details on the patient plan, provider plan, and today's orders for a selected assessment on the Assessment/Plan Details template in the A/P Details tab. Parent topic: Open the Assessments Tab Parent topic: Entering Assessments, Impressions, Differential Diagnoses, and Associated Details Parent topic: Document Assessments and Plans

NextGen® Adaptive Content Engine Help Enterprise 8

Document Follow-up Details

You can enter follow-up appointment and disposition details on the Follow-up/Disposition template. Open NextGen® Enterprise EHR. Open the SOAP template. In the Assessment / Plan panel, select the Follow Up button. The Follow-up/Disposition template opens. Follow-up/Disposition template The Follow-up/Disposition template is part of a group of templates that use the last assessment or diagnosis selected on any of the templates in the group as the working assessment. The application defaults to the current working assessment. If required, you can select another assessment, which becomes the new working assessment that carries forward to the other templates in the group. Do one of the following: Select the diagnosis in the grid. In the Follow-up section, select follow up along with other details and the suggested time for the follow-up visit. To select a new diagnosis or modify an existing assessment for the current patient, select Add/Edit Assessment. With the correct description selected

NextGen® Adaptive Content Engine Help Enterprise 8

Provide Patient Education Document

You can provide patient education documents in the Assessment / Plan panel. Note: The patient education details provided to a patient is encounter-specific. The details are not carried forward to subsequent encounters. Open NextGen® Enterprise EHR. On the SOAP template, expand the Assessment / Plan panel. Select My Plan in the navigation bar. The My Plan template opens. Select Patient Education and provide the necessary patient education documents. Parent topic: Enter Assessment Plan Details Parent topic: Documenting General Information of Patients Parent topic: Patient's General Information

NextGen Behavioral Health Suite Help 5.5

Document the Summary of the Patient's Assessments

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 - Assess/Plan, and then select OK. In the Life Goals, Strengths, Abilities and Barriers panel, enter the details of the patient's life goals, strengths, abilities, and barriers. In the Barriers to Care panel, document the obstacles to the patient's care. In the Service panel, enter the patient's care preferences and environmental support details. In the Clinical Formulation/Interpretative panel, document the patient's clinical summary. In the Treatment Recommendations/Assessed Needs panel, document recommendations for the patient's treatment and follow-up evaluations. Select Generate Document. Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates

NextGen Behavioral Health Suite Help 5.5

Document the Patient's Transfer Summary

You can document the patient's transfer details from one program to another. Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. Select Transfer Summary (BH), and then select OK. Select the program, specialty, and visit type. Select the patient's discharge date. To close the selected program for the patient, select the status of the patient's treatment in the program. In the Assessment/Diagnosis panel, document the patient's active diagnosis and assessment details. In the Transfer Summary panel, document the treatment details, post-transfer support details, risk details, and the reason for the patient's transfer. In the Transfer Plan panel, document the patient's active medications and transfer plans and instructions. Select Generate Document. Assessment and Diagnosis Functionality Parent topic: Transfer Summary