Transfer or Discharge Visit Workflow

NextGen® Adaptive Content Engine Help Enterprise 8

Screening and Admission Visit Workflow

The BH - Screening/Admission Note template is used to document information that a program or Emergency Room might need for their initial evaluation of a client. Information gathered here is the basis for a summarization of the services and possible interventions that are initially provided to the client. Generally, this is completed by the non-clinical staff at the practice and can be done separately from a Comprehensive Assessment exam. The BH - Screening/Admission Note template can be accessed at any time during an encounter by selecting Other Templates from the bottom section of the navigation bar. Document Admission Data Document Referral Source Enter Assessment and Diagnosis Details Add Additional Notes Enter Document Signatures Finalize Behavioral Health Billing Parent topic: Behavioral Health

NextGen® Adaptive Content Engine Help Enterprise 8

Individual Visit Workflows for Behavioral Health

Individual visit workflows for Behavioral Health enable the documentation of assessment and treatment plans for the individual client and are associated with the following Visit Types: Home Visit Psychiatric Diagnostic Evaluation Psychiatric Diagnostic Evaluation with Medical Services Psychotherapy - Individual Psychotherapy - Individual with E&M Virtual Visit Telephone Virtual Visit Video You can record new issues for the client on the Individualized Action Plan (IAP) template. The Comp Assess tab can be used to access the Treatment Recommendations/Assessed Needs panel. The IAP tab is used for the initial documentation of the client's goals, objectives and interventions for the assessed needs. The BH - IAP Review/Revision template is for updating any previously entered action plan elements. The BH - Relapse Prevention Plan template (Relapse Prev tab) is available from all of the individual psychotherapy visits. BH - Contact Note Template The BH - IAP Review/Revision Template BH - Indi

NextGen® Adaptive Content Engine Help Enterprise 8

Enter Transfer/Discharge Data

The assessment and diagnosis information of the client being transferred or discharged can be entered on the BH - Transfer/Discharge 1 template. Select the Transfer or Discharge option. Enter a Date. Select from one of the available statuses or choose Other to type an explanation of the client's situation. If enabled, click the DSM IV link that appears in the upper, right corner to launch the BH – DSM IV template. The display of the link is setup on the Behavioral Health section of the Practice Configuration system template. Complete the Diagnoses Section for Transfer/Discharge Enter a Discharge Summary and Treatment Enter Post Discharge Support Systems for the Client Record the Client's Discharge Risk Assessment Document Known Substance Use for Transfer/Discharge Summary Parent topic: Transfer or Discharge Visit Workflow

NextGen® Adaptive Content Engine Help Enterprise 8

Behavioral Health

You can use the templates for Behavioral Health to document information related to patient encounters specific to Behavioral Health. Document Encounters for Behavioral Health Visits DSM-5 Overview Billing in a Behavioral Health Encounter Behavioral Health Configuration Options Residential Services Workflows Intake Visits for Behavioral Health Individual Visit Workflows for Behavioral Health Group Visit Workflows Behavioral Health Medication Management Crisis Treatment Plan Workflow Screening and Admission Visit Workflow Transfer or Discharge Visit Workflow Related concepts Document Encounters for Behavioral Health Visits DSM-5 Overview Billing in a Behavioral Health Encounter Behavioral Health Configuration Options Residential Services Workflows Intake Visits for Behavioral Health Individual Visit Workflows for Behavioral Health Group Visit Workflows Behavioral Health Medication Management Crisis Treatment Plan Workflow Screening and Admission Visit Workflow Transfer or Discharge Visit

NextGen® Adaptive Content Engine Help Enterprise 8

Enter a Discharge Summary and Treatment

On the BH - Transfer/Discharge 2 (the Summary section tab in the Transfer / Discharge template set), describe the type of treatment received and how often in the Modality/frequency field. Type a specific Duration in the associated field. Describe the client's Compliance. In the Focus of Treatment field, click one of the following: The Focus of Treatment field to enter a brief description. The My Phrases link For more information about My Phrases, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide forNextGen®Adaptive Content Engine. Answer the question Were treatment goals achieved and provide a brief history. Parent topic: Enter Transfer/Discharge Data

NextGen® Adaptive Content Engine Help Enterprise 8

Document Known Substance Use for Transfer/Discharge Summary

In the Substance Use section on the BH – Transfer/Discharge 2 template, select from one of the following options: Alcohol Benzodiazepines Cocaine Opioids Nicotine Other To continue documenting in the template set, do one of the following actions: Click the Previous button. Click Next. Select the Assessment Section tab. Select the Plan Section tab. Parent topic: Enter Transfer/Discharge Data