Social Hx of a Comprehensive Assessment

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BH Hx Section Tab Overview

The Behavioral Health History (Bh Hx) section tab enables you to document the client's mental health history, substance use, risk assessment and to complete various screening tools. From this tab, users have access to the Past Medical History, Substance Use Assessment Exam, Social History - Tobacco, and Mental Status Exam templates. Enter Psychiatric Illness History Data Record Substance Use and Addictive Behavior Histories Substance Use Assessment Exam Document Mental Health and Addiction Treatment Service Histories Medication Information Panel Mental Status Evaluation Panel Record a Risk Assessment Enter Risk and Alert Histories Complete Behavioral Health Screenings on the Screening Tools Panel Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8

Visit Types for Comprehensive Assessment

The Comp Assess tab can be found in the following Visit Types: Case Consultation Chart Abstraction Chart Update Developmental Testing - Extended Developmental Testing - Limited Family Consultation Group Home Visit Home Visit Hospital Consult Intake No Medical Services Intake with Medical Services Onsite Consult Psychiatric Diagnostic Evaluation Psychiatric Evaluation with Medical Services Psychological Testing Psychotherapy - Family without client Psychotherapy - Family & Client Psychotherapy - Family Group Psychotherapy - Group Psychotherapy - Individual Virtual Visit Telephone Virtual Visit Video Parent topic: Comprehensive Assessment Template Set

NextGen® Adaptive Content Engine Help Enterprise 8

Explanation of the Functional Section Tab

The information documented on the Functional section tab helps in determining the client’s needs and setting up goals and objectives that are an integral part of the recovery plan. Each panel on the Functional section tab is structured similarly. Items are listed and the question is asked of each item: Not clinically indicated (NI) and Current need area (CN). To understand the difference between NI and CN, look at this example of each in case of Individual care skills: NI - The client shaves and maintains a clean appearance. CN - The client does not want to wear any clothes. A field is available to right of each item in which evidence to justify whether NI or CN can be typed. To the right of this field are No and Yes options to answer Individual/family served desires change now for each item. None of the questions are mandatory. Enter Activities of Daily Living Assign Clinical Assessment of Addictive Behaviors Assign Clinical Assessment for Behavior Management Record Family and Social

NextGen® Adaptive Content Engine Help Enterprise 8

Maintain a Record of the Client's Trauma History

The data in this panel copies forward from previous encounters and shares with the same panel on the Brief Assessment template. Expand the Trauma History panel. Trauma History If there is no history of trauma, select None reported to set the options below for the different types of experiences to be unavailable. Document the client's history and current experience of trauma in the Does individual report a history of, or current experience of section If Other is selected, an explanation or description can be typed into the adjacent field. Other pertinent information can be entered in the Provide relevant details field. Parent topic: Social Hx of a Comprehensive Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Document Sexual Issues

The field data on the Sexual Issues panel carries forward from encounter to encounter. Open the BH CA Social History template and expand the Sexual Issues panel. Enter the client's Sexual Preference. Free text or dictate notes about the client's sexual orientation and other relevant information in the Sexual history/concerns field. Parent topic: Social Hx of a Comprehensive Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Education History for an Adult Client

In the Education - Adult panel, under Education History, select No or Yes for Special needs. To document additional information, click the If Yes, comment field. Education-Adult Enter the client's Education, Type of school and highest Grade in school. Record the client's Major and select a Degree obtained from the associated list. To document vocational training, click Vocational training and indicate if the training was Completed. To indicate current enrollment, select If not completed, are you currently enrolled and enter additional details in the field that follows. To enter additional educational information, click the Comments field. Parent topic: Social Hx of a Comprehensive Assessment

Social Hx of a Comprehensive Assessment

Recommendations

BH Hx Section Tab Overview

Visit Types for Comprehensive Assessment

Explanation of the Functional Section Tab

Maintain a Record of the Client's Trauma History

Document Sexual Issues

Enter Education History for an Adult Client

BH Hx Section Tab Overview

Visit Types for Comprehensive Assessment

Explanation of the Functional Section Tab

Maintain a Record of the Client's Trauma History

Document Sexual Issues

Enter Education History for an Adult Client