Start a New Intake for a Brief Assessment

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

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

Complete the Diagnoses Section for Transfer/Discharge

In the Behavioral Health Diagnoses section, select any of the available links: Diagnosis Code Lookup Add Common Assessment Mandated Care Coordination In the required Diagnostic description field, click to launch the diagnosis search window. Selecting a description value automatically populates the ICD Code field or vice versa. In the Status field, click to select a value from the list. If appropriate, enter a Severity. If needed, enter a Differential dx, and/or Impression. To enter Specifiers, click one of the following: In the field to manually enter any required values The My Phrases link. For more information about My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. For chronic conditions, select the option to Mark diagnosis as chronic. Select the options to add the assessment to the Clinical problems, My tracked problems, and/or My favorites where applicable. Click Add To Grid. In the Physical Hea

NextGen® Adaptive Content Engine Help Enterprise 8

Enter DSM IV Assessment Details

In the Assessment/Diagnosis panel, click the DSM IV link to open the BH - DSM IV template. In the Axis I & II section, click the Copy Forward button to pull in previously entered assessment/diagnosis. Note: This button is enabled only if there is data available from a previous encounter. To open the Common assessment template, click Add Common Assessment. To document information for any person who should be contacted concerning this client, click Mandated Care Coordination. To enter a new diagnosis, click Add to open the Add or Update Assessment template. After a diagnosis has been entered, click Save & Close to return to the BH - DSM IV template. Do one of the following in the Axis III section: In the first available Diagnoses field, click to launch the diagnosis search window. Since the exact code for the client’s non-behavioral health diagnosis may not be apparent, you may not be able to select an Axis III diagnosis code. If available, select a code that was previously entered from

NextGen® Adaptive Content Engine Help Enterprise 8

Document Information in the Assessment/Plan Panel

The Assessment/Plan panel enables you to enter an assessment, generate the prenatal record, enter a follow-up appointment if not already done on the OB flowsheet, document which hospital the prenatal record must be sent to, and task to send the prenatal record to the hospital. The Prenatal Record button generates the cumulative Obstetric document for the pregnancy to date. At the first visit, it is important to generate the Prenatal Record to review all of the information for completeness and accuracy. After reviewing the Prenatal Record, the provider may note data that was not entered or view information that must be entered in the Problem/Detail list for easy viewing at subsequent visits. Select the Prenatal Detail tab Select the Assessment/Plan tab. Assessment/Plan panel To add an assessment, select Add/Update. Select any diagnosis in the Billing Diagnosis History section, the Clinical Problems section or the My Favorites section. Add or Update Asssessment The diagnosis is added to

Start a New Intake for a Brief Assessment

Recommendations

Record a Risk Assessment

Enter Assessment and Diagnosis Details

Start a New Intake

Complete the Diagnoses Section for Transfer/Discharge

Enter DSM IV Assessment Details

Document Information in the Assessment/Plan Panel

Record a Risk Assessment

Enter Assessment and Diagnosis Details

Start a New Intake

Complete the Diagnoses Section for Transfer/Discharge

Enter DSM IV Assessment Details

Document Information in the Assessment/Plan Panel