Update the Client's Current Assessment

NextGen® Adaptive Content Engine Help Enterprise 8

Record Substance Use and Addictive Behavior Histories

On the Substance Use/Addictive Behavior History panel, select the None reported check box if the client denies substance use or addictive behavior. Select one or more of the addictions options reported by the client. If needed, Other can be selected to type an historical issue that is not available on the panel in the associated field. Select the client's response for Drinks alcohol. If no information has been entered for the client's tobacco use history elsewhere, the read-only field is blank; to enter this data, click the Tobacco Usage link. If any of the addiction options apply, click the Substance Use link available at the top, right of the panel to gather more details. The BH Substance Use Assessment template opens. Enter Tobacco Usage Parent topic: BH - Brief Assessment Template Parent topic: BH - Psychiatric Evaluation

NextGen® Adaptive Content Engine Help Enterprise 8

Record Mental Status Exam Information

To record information on the Mental Status Exam panel, record a response to the question Does the individual require a full Mental Status Exam? Select Yes for a comprehensive record and click the Mental Status Exam link. Select the No if a full status exam is not necessary. Note: It is up to the provider to determine if a full mental status exam is required. Indicate whether there has been No significant change or No notable change in the following areas and type any notable change in the adjacent fields: Mood/affect Thought process/orientation Motor activity and speech Behavior/functioning Medical condition Substance use/addictive behavior Select the Not applicable check box if substance use or addictive behaviors do not apply to this client. Click the Substance Use link to open the BH Substance Use Assessment template. Parent topic: BH - Psychopharm Template

NextGen® Adaptive Content Engine Help Enterprise 8

Record Substance Use and Addictive Behavior Histories

On the Substance Use/Addictive Behavior History panel, select the None reported check box if the client denies substance use or addictive behavior. Select one or more of the addictions options reported by the client. Use the Other field can be selected to type an historical issue that is not available on the panel in the associated field. Select the client's response for Drinks alcohol. Click the Tobacco Usage link to enter the client's tobacco use. If any of the addiction options apply and a more in-depth evaluation is required, click the Substance Use link to enter more details. The BH Substance Use Assessment template launches. Enter Tobacco Usage Parent topic: BH Hx Section Tab Overview

NextGen® Adaptive Content Engine Help Enterprise 8

Substance Use Assessment Exam

BH Substance Use Assessment is a template on which a clinician or nurse can gather information about a client’s substance use history and how an addiction might negatively impact the client’s life. The information gathered on this template is configured to appear on whatever document is generated. It is one of just a few templates that launches with all but the top panel collapsed. This was done to make it easier find and use the appropriate panel. The recommended workflow is to expand a panel to document the information and collapse it when that section is complete. This template is launched from a Substance use link found on the Substance Use/Addictive Behavior panel. This link is also available on many templates throughout the Behavioral Health template set. Enter Chemical Use/Abuse History Add Substance Use Data Document Tobacco Use on the Substance Use Assessment Exam Add Gambling Information Document Impact of Substance Use/Addictive Behaviors of Life Areas Enter Toxicology Scree

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

Sign the Behavioral Health Document

Multiple people can sign the Behavioral Health document utilizing the Signature panel. Security on the Signatures panel is set up so that only the person who checks a signature line can alter it in any way. The client and/or parent/guardian’s signatures can be captured with electronic signature software. To document your signature in the Signatures panel, place a check mark next to the appropriate label. The current user’s name fills the Name field and the current date populates the date of the signature. Enter your Credentials. Select N/A to indicate that a signature is not applicable and to clear the fields of anything that may have been entered in the same row. Click the Send Task button to forward the template to the next person who needs to record their signature. If your signature does not fall under the preset options, enter your Name and Credentials in the Additional Staff section. Enter Comments as needed. Click Add. The signature details appear in the grid. Parent topic: BH -

Update the Client's Current Assessment

Recommendations

Record Substance Use and Addictive Behavior Histories

Record Mental Status Exam Information

Record Substance Use and Addictive Behavior Histories

Substance Use Assessment Exam

Enter Assessment and Diagnosis Details

Sign the Behavioral Health Document

Record Substance Use and Addictive Behavior Histories

Record Mental Status Exam Information

Record Substance Use and Addictive Behavior Histories

Substance Use Assessment Exam

Enter Assessment and Diagnosis Details

Sign the Behavioral Health Document