1. art and entertainment
2. shows and events
3. sports event

BERKELEY COMMUNITY MENTAL HEALTH CENTER
QA MANUAL
February 2011
Revised
1
Table of Contents
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Service Descriptions and Information: (See BCMHC website for Section 2 manual)
a. Crisis Intervention
b. Mental Health Assessment by a Non-physician
c. Individual Therapy
d. Family Therapy
e. Group Therapy
f.
Psychiatric Medical Assessment (MD and APRN)
g. Nursing Services
h. Injectable Medication Administration
i.
Mental Health Service Plan Development by a Non-Physician
j.
Targeted Case Management
Psychosocial Rehabilitative Service
K
l. Peer Support Services
m.
General Medical Record Standards
Guide for Determining Billable Time
Intake Procedures
Service Tickets
Fee Status and Billing Requirements
Change Forms
Billing Correction Procedures
Medical Records Signatures/Initials/Legilibility
Medical Records Organization
Correcting Documentation Errors in the Medical Record
Confidentiality/Privacy Issues Release of Information Form
Medical Records Security
Allergy Stickers
Guidelines for Clinical Care
Assessment Forms (Initial Clinical Assessment (ICA-Adult and CAF), Medical Assessment,
Hospital Discharge, Assessment update form
Individual Treatment Plan (ITP)
Crisis Management Form and Safety Plan
Discharge/Transition Planning and form
Treatment Summary Letters and Handling Requests for Information from the Medical Record
Approved Abbreviations
Diagnosis Codes in the CIS system By DSM code Alphabetically
Auditing Formats for DMH Quarterly Audits
Credentialing of Staff
Outcome Measures-GAF and CGAS training
General Guidelines for Documentation
Targeted Case Management Plan and Reviews for Clients with Medicaid
2
CIS
SERVICE
CODE
SERVICE DESCRIPTION AND ABBREVIATION
Effective DOS 07/01/10, CIS Update 07/01/10
UNIT
TIME
RATE/ MEDICAID MEDICAR
MAX
PROC
E PROC
UNIT
CODE
CODE
OTHER
PAYORS
PROC
Clinic Services
H001-O Crisis Intervention Service (CI)
15
40.00/16
H2011
Crisis Intervention Service via telephone (CI)Non
Physicain
15
40.00/4
H2011
H002
MH Assessment by Non Physician (Assmt)
30
58.00/6
H0031
H003
Individual Therapy (Ind Tx)
30
59.00/4
H004-001 Family Therapy, client present (Fm Tx)
30
H004-002 Family Therapy, client not present (Fm Tx)
H001-T
H005Group Therapy (Gp Tx)
GTX
H005Multi Family Group (Gp Tx)
MFG
H005Medication compliance / Caregiver Group
OTH
N/A
98966 (5
mins)
98967(11
90801
99058
98966 (5
mins)
98967(11
90801
90804
90804/20
90806/45
90808/75
90804/20
90806/45
90808/75
55.00/4
90847
90847
90847
30
55.00/4
90846
90846
90846
90853
90853
90853
30
26.00/8
90853
90849
90849
90853
90853
90853
30
26.00/8
H010
Injectable Medication Administration (Med. Adm.)
N/A
N/A
H012
Psychiatric Medical Assessment (PMA) 1st PMA by
MD
15
62.00/6
90801
90801
90801
H052
Subsequent PMA/ Med Management by MD
15
62.00/6
90862
90862
90862
H013
Psychiatric Medical Assessment-Advanced Practice
Registered Nurse (PMA-APRN) 1st PMS by APRN
15
52.00/6
90801TD
90801
90801
H053
Subsequent PMA/APRN/ Med Management by APRN
15
52.00/6
90862TD
90862
90862
H014
Behavioral health Screening Alcohol/Drug
15
12.61/2
H0002 HF
N/A
H0002
H016
Injecttion Administration (INJ. ADM) Note; This service
can not be billed when the client has any Medicaid
coverage
15
25.00/1
N/A
96372
96372
H017
MH Service Plan Development by Non Physician (SPD)
MD ONLY, w/o pt or fam Note: (30 mins for Medicare)
15
55.00/2
H0032
99367
99367
15
MH Service Plan Development by Non Physician via telep
H021-O Nursing Services (NS)
15
H021-M Nursing Services Medication Monitoring (NS)
15
55.00/2
H0032
51.00/7
51.00/7
T1002
T1002
H021-T Nursing Service via telephone (NS)
15
51.00/7
T1002
99441/5
99442/11
99443/21
N/A
M0064
98966/5
98967/11
98968/21
99441/5
99442/11
99443/21
T1002
M0064
98966/5
98967/11
98968/21
H017-T
See Table See Table
See Table
H031
H032
TCM Services
H031 Targeted Case Management (TCM)
H032 Concurrent Case Management (CM)
Rehab Services for CMHC
15 **
15
37.50/8
35.00/8
T1017
T1016
N/A
N/A
90882
90882
H056
Rehabilitation Psychosocial Service (RPS)
15
26.62/64
H2017
N/A
H2017
H057
Family Support (FS)
15
26.62/64
S9482
N/A
S9482
H058
Behavior Modification (BMod)
15
26.62/64
H2014
N/A
H2014
H059
Peer Support Service (PSS)
15
26.62/64
H0038
N/A
H0038
Place of Service Codes:
NOTES:
Medicare - Medicare is billed "11" always.
Medicaid - if POS is "11" - Medicaid is billed "53"
if POS is "03" - Medicaid is billed "99" otherwise - Medicaid is billed POS
03 - School (Medicaid is billed "99"), 11 - Doctor's Office
12-Patient's Home, 21-Inpatient Hosp,22 for Outpatient Hospital
23-Emergency Room, 51-Inpatient Psych.Facility 31 for Skilled
Nursing Facility
Modififers 52 Reduced services
25 Significant,Separately Identifiable E/M services bu the same physician
on the same day of other services.
For Medicare and Other Payors, the number of units: (1), (2), (3) will
(1), (2), (3) designate the CPT code billed. Services rendered by a non-licensed
clinician cannot be billed to Medicare.
53-Community Mental Health Center
Unlisted Facility (when no other exists)
99-Other
CMHC REFERENCE LIST
SECTION ISERVICES AND DESCRIPTIONS (SEE SECTION 2 OF MEDICAID MANUAL FOR DETAILS)
CRISIS INTERVENTION (CI) H001
Documentation: (FIRSD)
• Focus of session, nature of crisis
• Interventions provided by staff
• Response of client to intervention
• Status of client at end of sesssion
• Disposition at end of session
General Purpose: To stabilize the client, identify the precipitants/causal events of the crisis, reduce immediate
personal distress felt by the client and reduce the chance of future crises through preventive strategies.
Provided by: MHP
POC requirement: Not required to be listed on POC
PRN frequency if listed
Unit: 15 Minutes
Billing restrictions:
Maximum units/day: 16 face to face; 4 telephone
3
MH ASSESSMENT BY NON-PHYSICIAN (Assmt) H002
Documentation:
• Initial Clinical Assessment (CSN should reference documents)
• Annual Assessment (CSN should reference documents)
• CSN
General Purpose: To determine the nature of the client’s problems, resources to help solve the problems,
establish diagnoses and develop a treatment plan, ascertain the client’s progress during the course of treatment,
response to treatment, need for continued participation in treatment, or change in behavior or condition.
Provided By: MHP
POC Frequency: Not required to be on POC
Billing restrictions:
If listed, PRN
Unit: 30 Minutes
Maximum units/day: 6
4
INDIVIDUAL THERAPY (IND TX) H003
Documentation:
• Focus of session
• Interventions of staff
• Response of client to intervention
• Progress of client in relation to the treatment goals
• Plan for next sessions
General Purpose: To enhance the client’s ability to manage their emotions and behaviors through planned
therapeutic interventions that are therapeutic or supportive in nature. Must be face to face with client.
Provided By: MHP
POC: Must be on the POC
Must have planned frequency
Unit: 30 Minutes
Billing Restrictions:
Maximum units/day: 4
5
FAMILY THERAPY (Fm Tx) (Client, Present or not present) H004
Documentation:
• Focus of session
• Intervention of staff
• Response of client/family
• Progress in relation to the treatment goals
• Plan for next sessions
General Purpose: To restore, enhance or maintain the function of the family unit to facilitate the client
improvement. Identified client must be the focus of the sessions. Includes interventions with the client’s family
unit with or on behalf of the client.
Provided by: MHP (H004-001 with client; H004-002 client not present)
POC Frequency: Must be listed on POC
with planned frequency
Unit: 30 Minutes
Billing Restrictions: None
Max Units Billed/Day: 4
6
GROUP THERAPY (Gp Tx) H005
Documentation:
• Focus of group or activities in the group
• Intervention of staff
• Response of client to the interventions
• Progress of client in relation to the treatment
• Plan for the next sessions
General Purpose: Face to face interventions that can be therapeutic, psychoeducational, or supportive in
nature to restore, enhance or prevent the deterioration of the client’s levels of role performance
through group support, especially when interpersonal relations play a role in triggering, maintaining, or
worsening the client’s symptoms and problems, or when the client experiences co-occurring disorders. Provided
to all clients adults and children and to caregivers or Multiple Family Groups.
Ratio: 1:12; if MFG, no more than 6 family units with no more than 12 family members for 1 staff
Provided by: MHP (Caregiver and Med Compliance may be done with Non-MHP bachelors level under
supervision of MHP
POC Frequency: Must be listed on the POC
Must have planned frequency
Units: 30 minutes
Billing Restrictions:
Max units/day: 8
7
PSYCHIATRIC MEDICAL ASSESSMENT (PMA/ PMA-APRN) H012
Documentation: PMO note with CSN to reference the note
General Purpose: To assess the mental status and need for treatment, including co-occurring disorders; provide
psychiatric diagnostic evaluation; specialized care, medications and referrals
Provided by: MD (H012) or Advanced practice RN (H013). (The MD must see for the initial PMA before the
APRN can render the service.) One substantial PMA (H012) may be billed per year or if circumstances change.
H052- Subsequent PMA
H053- Subsequent APRN PMA
Special Requirements: If no face to face treatment service has been provided in 6m, must do a new PMA
It is strongly recommended to have a PMA done at least every 6 mo if the client is prescribed neuroleptic
medication
POC Frequency: Does not have to be listed
If listed, PRN
Units: 15 Minutes
Billing Restrictions:
Max units/day: 6
8
NURSING SERVICES (NS) H021
Documentation:
Med Monitoring (H021-M):
• Current meds
• Side effects/adverse reactions
• Compliance
• Effectiveness of meds
• Issues of co-occurring substance abuse
Psych Nursing (H021-O):
Focus
Intervention by nurse/results of any tests
Response of client to intervention
Status of client and needs in reference to goals
Health Questionnaires (i.e., Medical Assessment)
General Purpose: To address the medical/physical needs of the client, and prevent unnecessary psychiatric
hospitalizations. Provided face to face or telephonic with the client or on behalf of the client. Used for
monitoring medication, promoting health, educating client, provide follow up nursing care.
Provided by: RN, under supervision of MD or APRN
POC Frequency: Does not have to be listed on POC
If listed, PRN
Units: 15 Minutes
Billing Restrictions:
No more than 2units/phone/day.
Max Units/Day: 7
9
INJECTABLE MEDICATION ADMINISTRATION (Med Adm) H010 and H016
Documentation:
• Medication Administered
• Dosage given (quantity and strength)
• The route (IM, ID, IV)
• The injection site
• Side effects or adverse reactions
General Purpose: To restore, maintain, or improve the client’s role performance or mental status
Provided by: RN, MD, APRN, LPN
POC Frequency: Does not have to be listed on POC
If listed, PRN
Units: Billed per cost of medication
Billing Restrictions: None
Max units/day: N/A
10
MH SERVICE PLAN DEVELOPMENT BY NON-PHYSICIAN (SPD) H017-3
Documentation must contain:
• Focus of the staffing (one or more of the following):
a) client’s treatment needs
b) monitoring and review of POC
c) diagnosis
d) discharge plans
e) treatment strategies
f) types and frequencies of services
• The physician’s recommendations
General Purpose: To jointly assess the client’s mental and physical strengths, limitations, social history,
support systems, in order to establish treatment goals and services to reach those goals.
Provided by: MHP and Physician jointly
Special Requirements: Both MHP and physician must sign the note. May be delivered by telephone.
POC Frequency: Does not need to be listed on POC
IF listed, PRN
Billing Restrictions: None
Units: 15 Minutes
Max units/day: 2
If you spend at least 8 minutes staffing, you may bill one unit of SPD (15 min). Your documentation must
reflect the time billed. If you bill 20 minutes, your note should reflect that amount of time or billing will be
denied.
11
SEE SECTION 26
TARGETED CASE MANAGEMENT (TCM) H031 CM (H032)
Documentation:
• Purpose of contact
• Who was contacted
• Components of TCM utilized
• Results of contact
• Plan for continued follow up
General Purpose: To help clients gain access to appropriated medical, social, treatment, educational, and other
needed services, through locating, coordinating, and monitoring the necessary and appropriate services.
Components of TCM: Documentation must support that the TCM billed includes at least one of the
following:
1. Assists the client in obtaining required educational, treatment, residential, medical, social, or other support
services through accessing available services or advocating for service provision.
2. Contacts (telephone or face to face) with providers with social, health, and rehabilitation services to promote
access to and appropriate use of services by the client, and coordination of service provision by multiple
providers.
3. Monitors client progress through the services accessed by the client and performs periodic review and
reassessment of treatment
needs.
4. Arranges and monitors patient access to primary health care provider (non-center physician). Includes
written correspondence sent to a primary health care provider (non-center) which gives a synopsis of the
mental health treatment the client is receiving.
5. Coordinates and monitors other health care needs of the client by arranging appointments for non-center
medical services with follow up appointments.
6. Staffing meetings related to receiving consultation and supervision on a specific case to facilitate optimal
case management.
7. Contact with the client dealing with specific and identifiable problems of service access which requires the
case manager to guide or advise the client in the solution of the problem of service access.
8. Contacts with family, representatives of human service agencies, and other service providers to form a
multidisciplinary team to develop a comprehensive and individualized service plan, which describes the
client’s problems and corresponding needs, and details services to be accessed or procured to meet the
client’s needs.
9. Preparation of a written report which details the client’s psychiatric status, history, treatment, or progress
(other than for legal or consultative purposes) for physicians, or other service providers.
Eligibility: TCM can be rendered to persons eligible to receive this service: Adults with a diagnosis of a Major
Disorder included in the DSM: Schizophrenias, Or Major Affeftive DO, OR Severe Personality DO, OR
Psychotic DO, OR Delusional DO, OR diagnosis of a mental disorder and at least one hospitalization; Children
with a DSM diagnosis of emotional disturbance with a duration of more than six months or projected to
continue for more than six months, or a DSM diagnosis for a neurological impairment and a severe emotional
disturbance with a duration of more that two years against published criteria, or needing services of more than
12
two agencies, or needing more than 2 types of services from mental health., or has been served in a paychiatric
hospital or has been served in an intensive residential program or needs intensive residential services.
Hierachy Guidelines: Clients receiving services from other agencies/providers must be determined whether
they have a Primary Case Manager. Clinicians should call the specific agency/provider to inform them that the
client is seeking service here and find out if the other agency is providing TCM. If they are the Primary Case
Manager, MH will provide concurrent case management (CM) services consisting of: (H032)
Notifying the Primary Case Manager of
a. Changes in the client/family situations
b. Needs, problems, or progress
c. Required referrals
d. Program planning meetings (not billable)
Provided by: MHP, Non-MHP Bachelor level, RN licensed by state
ITP Frequency: Not required to be listed on ITP
to 2 units/day
If Listed, PRN
Units: 15 minutes
Billing Restrictions: Telephone calls with clients restricted
See list of non billable services
May not be provided in special waiver programs
Max units/day: 8
13
REHABILITATIVE PSYCHOSOCIAL SERVICE (RPS) H056
Documentation:
• Focus of the objectives of the activities
• The nature of the activities in which the client participated. (These shall be within the service description)
• Intervention of staff
• Response of the client to these interventions regarding the development of the psycho/social/behavioral
skills
• The progress of the client, during the week, in reference to the treatment goals
• The plan for the next week /session.
General Purpose: To prepare clients to function as actively, adaptively, and independently in society as
possible and appropriate. Are provided to adults diagnosed with a serious mental illness and severely
emotionally disturbed children. RPS planned and structured activities include:
• Rehabilitative Interventions
• Interpersonal Skills
• Daily Living Skills
• Restorative Independent Skills
Provided by: MHP, Non-MHP-Bachelor level (Notes must be co-signed by MHP), RN
Ratio: 1:12 or individually for adults and children
Must be on POC and used within 45 days or has to be re-authorized by physician.
POC Frequency: Must be listed on the POC with a planned frequency and implemented within 45 days or will
need to be re-certified with physician's initial and date on POC
Billing Restrictions:
Units: 15 minutes
Max units/day: 24
15
PEER SUPPORT SERVICES (PSS) H059
Description:
Peer Support Service is person-centered with a recovery focus. Allows clients to direct their own recovery and
advocacy processes. Promotes skills for coping with and managing symptoms while facilitating the utilization
of natural resources and the preservation and enhancement of community living skills. Services are multifaceted and emphasize the following:
Personal safety
Confidence
Planning
Self- worth
Growth
Self-advocacy
Introspection
Connection
Personal fulfillment
Choice
Boundary Setting
The helper principle
Crisis Mgmt
Meaningful Activity
Communication skills
Eligibility:
Adult clients diagnosed with severe mental illness and/or co-occuring disorders
Ratio:
1:1 or in small groups of no more than 1:8
POC Requirements:
Must be on ITP with PRN frequency
Special Restrictions:
Must be provided under the supervision of MHP
Staffing must occur every 2 weeks.
MHP must make evaluation at least every 6 months.
PSS must have annual training
Billing:
15 min units 16 units/day
18
GENERAL MEDICAL RECORDS STANDARDS
•
•
•
•
•
•
•
•
•
•
•
•
Each client shall have a medical record.
Medical record shall include sufficient information to justify treatment and permit a clinician not familiar
with the client to evaluate the course of treatment.
Medical records must be arranged in logical order.
Kept confidential in conformance with HIPAA
Medical records must be consistently organized, current, and filed in chronological order.
Medical records must contain:
¾ Initial Clinical Assessment
¾ PMA
¾ All treatment plans, reviews, and addenda
¾ Physician’s orders, lab results, lists of medications and prescriptions (when applicable)
¾ Clinical service note within 72 hours of service
¾ Copies of any testing
¾ Copies of all written reports
¾ Consents and eligibility information
¾ Any other documents relevant to client’s care
Consents: A signed consent must be obtained from all clients at each admission. If the client refused to
sign, the clinician should indicate in a CSN why. If client is unable to sign, a family member may sign in an
emergency, or if alone, the MHP and one other person can sign saying the client is unable to sign due to
emergency situation.
Abbreviations: Only approved abbreviations of services and accepted abbreviations maintained by the
service provider may be used.
Legibility: All documents must be typed or legibly written in black or blue ink.
Error Correction: Clearly draw one line through the error and write “ME” beside it. Enter the correction
and initial and date the error. No correction fluid may be used.
Late Entries: Should only be used to correct a genuine error of omission or to add new information that
was not discovered until a later date. Identify the new entry as “late entry.” Enter the current date and time.
Identify or refer to the date and incident for which the late entry is written. Sign and date the late entry.
Document as soon as possible.
Physician Responsibility: The physician must direct all treatment. A PMA is required for all clients within
90 days of admission. The physician must sign the POC within 90 days. The physician must initial and date
any additions of service or change in frequency on the service plan. The physician must sign the rollover
POCs on, or no earlier than 30 days prior to, the due date (based on admission date).
19
SECTION 2
GUIDE FOR DETERMINING BILLABLE TIME
BILL TIME is direct face to face contact (with the client or caregiver) for all services except those that can be
delivered “on behalf” of the client or over the telephone (see service descriptions). Billable time starts from the
time you greet the client at the front door. As you are escorting the client to your office, you are making the
critical first impressions on the mental status of the client. The clock continues to run until you say goodbye at
the front check-out window.
STAFF TIME must be less than or equal to Bill Time.
NO-CHARGE:
If a service is not to be charged, you must record the bill time and mark “NC” above it. Mark “07” in the payor
slot on the face of the ticket.
NON-BILLABLE ACTIVITIES:
There are some activities that are done for and on behalf of clients that are not allowed to be billed. The
following list is not all encompassing and is intended as a guide.
1. Travel time.
2. Attempted phone calls
3. Attempted home visits.
4. Attempted face to face contacts.
5. Record reviews.
6. Completion of any specially requested information regarding clients from the State office or from other
agencies for administrative purposes.
7. Services provided to institutionalized Medicaid clients (i.e. DJJ, prisons/jails, DMH hospitals, ICF,
ICF/MR facilities, IMDs, long term hospitalization outside SC DMH , etc.)
8. Recreation or socialization with a client. Professional judgment should be exercised in distinguishing
between billable and non-billable activities.
9. Documentation of service notes.
10. Completion of MIS reports and monthly statistical reports.
11. Unstructured time with clients. Inactivity, free and unstructured time may be necessary for a client, but
is not part of billable service.
12. Educational services provided by the public school system, such as home bound instruction, special
education, or defined educational courses (GED, Adult Development). Tutorial services in relation to a
defined education course are non-billable.
13. Filing and mailing of reports.
14. Medicaid eligibility determinations and redetermination.
15. Medicaid intake processing.
16. Prior authorization for Medicaid services.
17. Required Medicaid utilization review.
22
18. EPSDT administration.
19. “Outreach” activities in which an agency or a provider attempt to contact potential Medicaid recipients.
20. Participation in job interviews.
21. The on-site instruction of specific employment tasks.
22. Staff supervision of actual employment services.
23. Assisting the client in obtaining job placement.
24. Assisting the client in filling out an application.
25. Assisting the client in performing the job or performing the job for the client.
26. Drawing the client’s blood and/or taking the specimen to the lab.
27. Visiting a client while he is in another mental health service program.
28. Assisting the client get medication kept at the CMHC.
29. Scheduling appointments with the physician, or any other clinician at the CMHC.
BILLABLE ACTIVITIES:
See attached chart for guide to determining billable times for services.
BILLING
Guide for Determining Billable Units
CIS
Codes
Service
Mins
per
Unit
Max
Units
per
Day
1 Unit
2 Units
3 Units
4 Units
5 Units
6 Units
7 Units
8 Units
H001
Crisis Intervention
15
16/4
8-15
23-30
38-45
68-75
83-90
98-105
113-120
H002
Assessment-MHP
30
4
16-30
46-60
76-90
106-120
H003
Individual Ther.
30
4
16-30
46-60
76-90
106-120
H004
Family Therapy
30
4
16-30
46-60
76-90
106-120
H005
H0
Group Therapy
PRS
30
15
4
20
16-30
8-15
46-60
23-30
76-90
38-45
106-120
58-60
68-75
83-90
98-105
113-120
H010
Injectable Med.
Administration
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
H012
PMA
15
6
8-15
23-30
H013
APRN-PMA
38-45
53-60
68-75
83-90
98-105
113-120
H015
Skills Training
and Development
15
24
16-30
46-60
76-90
106-120
136-150
166-180
196-210
226-240
H017
SPD
15
2
8-15
23-30
H018
Mental health
Services, NOS
15
20
8-15
23-30
38-45
68-75
83-90
98-105
113-120
H020
Comprehensive
Community
Support
15
12/24
8-15
23-30
38-45
68-75
83-90
98-105
113-120
H021
Nursing Services
15
7
8-15
23-30
38-45
53-60
68-75
83-90
98-105
113-120
58-60
58-60
58-60
9 Units
10 Units
128-135
143-150
N/A
N/A
256-270
286-300
128-135
143-150
128-135
143-150
128-135
143-150
128-135
143-150
Max of 2/phone
H025
Peer Support
Service
15
7
8-15
23-30
38-45
53-60
68-75
83-90
98-105
113-120
H031
TCM
15
8
15
30
45
60
75
90
105
120
H032-
Concurrent TCM
15
8
15
30
45
60
75
90
105
120
15
64
68-75
83-90
98-105
113-120
H061
WRAPS-CG
8-15
23-30
38-45
58-60
23
CIS
Codes
H063
Service
WRAPS-BI
Mins
per
Unit
Max
Units
per
Day
15
64
1 Unit
2 Units
3 Units
8-15
23-30
38-45
4 Units
58-60
5 Units
6 Units
7 Units
8 Units
68-75
83-90
98-105
113-120
9 Units
10 Units
128-135
143-150
24
SECTION 3
INTAKE PROCEDURES
ADMINISTRATIVE PROCEDURES FOR COMPLETING AN INTAKE
Ways of Accessing Services
¾
¾
¾
¾
Routine Admission to BCMHC Outpatient Services-Scheduled Appointment
Emergency Admission to BCMHC Outpatient Services- Unscheduled Appointment
Emergency Inpatient Admission- After hours Visit-No Referral to BCMHC
Emergency Inpatient Admission- After hours Visit- Referral made to BCMHC
Forms to Complete
If Applicable:
Clinical Assessment Form
Medical Assessment Form
Crisis Management Form
Copy of Commitment Papers
Hospital Discharge Assessment
Screen 8
CSN-white copy
CSN-Yellow copy
Discharge data if closing case
Trauma Assessment
Outcomes (Adult and CBCL)
Satisfaction Survey
Disposition of Forms
Scheduled Admission
Emergency After hours
Chart-Section 4
NA
Chart-Section 4
NA
Chart-Section 4
Front desk
Section 2 chart
Section 2 chart
Section 4 chart
NA
Wall divider-Mail room
Wall divider in Mail room
Drawer in Mail room
Drawer in mail room
Chart-Section 4
Chart Section 4
Chart-Section 1 (white copy
Chart Section 1
Wall Divider in mail room (Yellow)
Wall Divider in mail room (Yellow)
Chart Section 4
NA
To QA for scoring, then ChartNA
Section 4Outcomes office (Barbara/Cathy)
NA
See the next pages for codes to use in the Screen 8 form.
25
Guide for Completing CIS Information
Screen 8 Form
Referral Source:
3K Aiken -Barnwell MHC
3H AOP MHC
3J Beckman MHC
3W Berkeley MHC
46 Bryan Hospital
49 Byrnes Medical Center
67 Campbell Nursing Home
3G Catawba MHC
3B Chas/Dor MHC
CL Clergy
3M Coastal Empire MHC
3D Columbia Area MHC
VA Veterans Administration
VR Vocational Rehabilitation
CR Courts
OS Out of State
44 DGNCC-Columbia
DA Drug and Alcohol
FF Family or Friend
GH General Hospital
3A Greenville Mhc
47 Harris Hospital
HS Health Service
LF Law Enforcement
3T Lexington MHC
MR Mental Retardation
71 Morris Village
NH Nursing Home
CC Community Care Home
OT Other Referrals
42 Crafts Farrow
YS Youth Services
MH
PP
PH
3F
SH
SF
SS
41
3C
3N
65
3R
MP
3P
3E
58
3S
Private MH Professional
Pvt Physician/Psychiatrist
Pvt Psychiatric Facility
Santee-Wateree MHC
School/Special Class
Self
Social Services
State Hospital
Spartanburg MHC
Tri-County MHC
Tucker Center
Orangeburg MHC
OtherMedProfessionals
Waccamaw MHC
Pee Dee MHC
William S. Hall
Peidmont MHC
48 DGNCC-Rock Hill
Presenting Problem
0 Psychiatric
1 Substance
2 Psych/Substance
3
4
Psychiatric/MR
Psych/Subst/MR
Type of commitment
01 Voluntary
02 Emergency
03 Judicial
04 Circuit/Criminal Court Order
Type of Papers
01 Psychiatric
02 Alcohol/Drug
03 Nursing Home
5. Substance/MR
6. All Others
05
06
07
08
Family Court
Medical Certification
Order of MH Commission
Court to Judicial
04
05
Forensic
Court Order for Outpatient Treatment
Living Arrangement:
Cat
Description
Code
Explanation
01
Private
Residence/Household
1A
Lives alone in a household and performs a majority of their daily activities and personal care independent of
help from others.
1B
Lives with relative n a household and performs a majority of their daily activities and personal care
independent of help from others.
1C
Lives with non-relative in a household and performs a majority of their daily activities and personal care
independent of help from others.
1D
Lives with relative in a house hold and is dependent on help from others in household in performing a
majority of their daily activities and person al care.
1E
Lives with non-relative in a household and is dependent on help from others in household in performing a
majority of their daily activities and personal care
1F
Adult supervised living: Lives alone or with others in a household with Center staff on site.
1G
Homeshare: Lives in a household with others who receive a DMH stipend for TLC care
26
Cat
Description
Code
Explanation
1H
Youth Supervised Independent Living Level I: Youth with moderate emotional and /or behavioral problems
lives in a household with trained alternative parent in preparation for independent living.
1J
Youth Supervised Independent Living Level II: Youth with severe emotional and or behavioral problems
lives in a household with trained alternative parent in preparation for independent living
1K
Foster Care: Living in a home of foster care parents-approved through DSS.
02
Homeless shelter
2A
Homeless and living in a shelter.
03
On the street
3A
Homeless on the street/in a park, etc.
04
Jail or correction
facility
4A
Resides in a secure incarcerated environment such as a jail, State/federal prison, DJJ facility, correctional
unit of a medical/psychiatric facility, etc.
05
Other residential or
institutional facility
5A
Therapeutic Foster Care-Level 1: Youth needing supervision for moderate emotional and/or behavioral
problems living in individualized care provided by specially trained foster care parents
5B
Therapeutic Foster Care-Level 2: Youth needing supervision for moderate to more severe emotional and/or
behavioral problems living in individualized care provided by specially trained foster care parents
5C
Therapeutic Foster Care-Level 3: Youth needing supervision for severe emotional and/or behavioral
problems living in individualized care provided by specially trained foster care parents
5D
Community Residential Care Facility- Standard-Type 1: Living in a community residential care facility
offering room and board with minimal supervision in personal care as outlined in DEHEC licensure.
5E
Community Residential Care Facility- Type 2: Living in a community residential care facility that provides
a higher level of care and rehab services. The CRCF has contracted with DMH for enhanced services not
provided for in a standard CRCF.
5F
Community Residential Care Facility- Type 3: Living in a community residential care facility operated by
DMH and provides a very structured and high livel jof personal care and rehabilitative services.
5G
Group Home-Moderate: Living in a group home with level of supervision and intensity of program to
manage and treat youth with moderate emotional and/or behavioral problems. Approved by DSS.
5H
Group Home-High Management: Living in a group home with level of supervision and intensity of program
to manage and treat youth with severe emotional and/or behavioral problems. Approved by DSS.
5J
Residential Treatment Facility: Living in a highly structured and secure treatment environment with
intensive professional multi disciplinary focus for youth. Licensed by DHEC
5K
Resides in an inpatient setting in a facility such as a psychiatric hospital, a medical hospital, etc. but not a
correctional unit.
5L
Nursing home: Living in a facility provideng comprehensive nursing care on a 24 hour basis.
9A
Not collected/Not Available/Unknown/Not reported
99
Not collected/Not
available
Other questions about living arrangements when screen is chosen:
Does the consumer live in SCDMH housing? (At present time the answer for Berkeley County consumers should be NO.)
Is the consumer receiving a housing rent subsidy? (Check those that apply)
Household Composition:
1
Lives alone
2
Lives with family/relatives
3
Lives with significant other(s)
4
Group/Institutional Living
5
Not appropriate
Competency: (Jail inmates only)
01 NGRI
02 Not Adjudicated
03 Guilty but Mentally Ill
04
05
06
Not competent to stand trial
Memo of Agreement/Mental
Examination to determine competency
27
Psychiatric Admissions
Inpatient:
46 Bryan Hospital
42 Crafts Farrow
GH General Hospital
47 Harris Hospital
NN None
IP Other Inpt Hospital
PH Private Psychiatric Hospital
41 SC State Hospital
UN Unknown
58 Wm S Hall Psych Inst
71 Morris Village
VA Veterans Admin
Outpatient:
3K Aiken Barnwell MHC
3H Anderson Oconee Pickens MHC
3J Beckman MHC
3W Berkeley MHC
3G Catawba MHC
3B Chas/Dor Mhc
3M Coastal Empire MHC
3D Columbia MHC
GH General Hospital
3A Greenville MHC
3T Lexington MHC
3P Waccamaw MHC
54
Wm S Hall Outpt Services
NN
3R
MP
3E
3S
MH
PP
PH
3F
3C
3N
UN
None
Orangeburg MHC
Othermedical professional
Pee Dee MHC
Piedmont MHC
Private MH professional
Private Physician/Psych
Pvt Psych Facility
Santee-Wateree MHC
Spartanburg MHC
Tri-County MHC
Unknown
GAF/CGAS Codes:
See QA manual Section 29
Employment Codes:
Employment Status Detail
Employment Status Grouping
Code
Description
Explanation
Code
Description
A0
Consumer Operated Business
Employed in a business operated by consumer(s).
01
Competitive
A1
Self-Employed
Owner of own business
01
Competitive
B0
Employed Competitively
Employed in a competitive job situation-non consumer run business
01
Competitive
B1
Active Military
On active duty in the US Military (Army, Navy, Air Force, Marines,
Coast Guard, etc.)
01
Competitive
M1
Employed Informally
Day Laborer/Casual Labor
01
Competitive
C0
Supported Employment
Employed on a job that is not time limited with necessary support
provided by a job coach
02
Supported Employment
D0
Time Limited Transitional
Employed in a time limited job with on-going job support to maintain
the worker role
02
Supported Employment
F0
Mobile Work Crew
Member of a supervised work crew in a MHC or similar community
setting with job support from staff
02
Supported Employment
G0
Enclave
Eight of fewer consumer employees in one location with continous
supervision and ongoing job support from staff.
02
Supported Employment
I0
Vocational Volunteer
Volunteers in a work setting to improve vocational skills
03
Unemployed and desiring work
P1
Unemployed and seeking work
Currently unemployed-desiring and seeking employment
03
Unemployed and desiring work
P2
Unemployed and not seeking
work
Currently unemployed and desiring work but currently not seeking
employment
03
Unemployed and desiring work
J0
Educational Placement and
training
Enrolled in a specific educational program to increase abilities for
competitive employment
03
Unemployed and desiring work
H0
Unpaid family worker
Works in a family owned business and does not receive a salary
04
Not in Work force and not
seeking or desiring work
J1
Student over 17 years old
Student over 17 in an educational program and currently not
desiring/seeking work
04
Not in Work force and not
seeking or desiring work
J3
Student under 18 years old
Student under 18 in an educational program
04
Not in Work force and not
seeking or desiring work
Maintains a household with or without family-does not work outside
Not in Work force and not
28
K1
Homemaker/Caretaker
the home
04
seeking or desiring work
K2
Retired
Retired form the workforce and not desiring or seeking employment
04
Not in Work force and not
seeking or desiring work
K3
Disabled
Currently on disability and currently unable to work
04
Not in Work force and not
seeking or desiring work
J2
Preschool
Children under age 5 not attending an educational program
04
Not in Work force and not
seeking or desiring work
Z1
Other
Any employment status not listed above except unknown
05
Other/Unknown
Z9
Unknown
Consumer’s employment status is unknown
05
Other/Unknown
Employment levels:
Code
Description
Explanation
01
Full time
Working 35+ hours per week
02
Part time
Working < 35 hours per week
03
Not employed
Unemployed
04
Not applicable
Not applicable or unemployment level unknown
Job Classification
Professional
Managerial
Technical
Construction/Contractor
Clerical/Sales
Service
Other
Examples
School teacher, physician, attorney, librarian, nurse, etc
Sales manager, trade manager, public administration manager
Engineer, analyst, lab technician, scientist,etc
Plumber, carpenter, electrician, mechanic, carpet installer
Secretary, file clerk, data entry, bookkeeper, cashier
Wait staff, preschool helper, hair dresser,
---------------
Job Class
Code
A0
B0
C0
D0
E0
F0
G0
29
Office and Location Codes—What do they mean? When do I use them?
We have tried to simplify the office/location codes. You will notice that some of the old codes are no longer in
use. If you have any questions about this, please, do not hesitate to give us a call.
B27- Used by Access Center for intake admissions. Code changes as they are assigned to clinicians.
B35- Used by all adult clients seen who are NOT in an emergency
B45- Used by Homeshare clients in all situations
B48- Used by IPS workers when working specifically on employment with clients
B51- Used for ACT (Like) clients at all times
B54- Used for children in treatment all diagnosis and circumstance except emergencies
B87- Proviso children
C34- All children seen by outstationed DSS worker
Q56- All children seen in ICS
Crisis Codes: By phone or in person
B70- Crisis for adults during office hours MC office
B80-Crisis for Children during office hours MC office
G70- Crisis for adults after hours
G80- Crisis for children after hours
Moncks Corner
B27
Intake and Triage/Assessment
B35
Continuing Treatment and Support
B45
Homeshare
B48
Employment-IPS
B51
ACT (Like)
B54
Continuing Treatment and Support-CAF
B70
Crisis Intervention/office hours/Adult
B71
Crisis Diversion
B80
Crisis Intervention/office hours/CAF
G70
Afterhours/Adult Crisis Intervention
G80
Afterhours/ Child Crisis Intervention
B87
Proviso
Q56
Continuing treatment and support/CAF/ICS
C34
Berkekey DSS/Child Welfare Initiative
30
SECTION 4
SERVICE TICKETS
A.
Batch Number: Completed by front office staff on all tickets.
B.
Payor Codes: Completed by clinical staff. Use all codes that apply.
1- Prepaid
2- Self Pay
3- Private Insurance
4-Medicaid
5- Medicare 6- Champus 07-No Charge
C/D.
Location and Office Codes: Completed by clinicians on all tickets. Codes are client specific for
service area to which they belong.
E.
Place of service:
Pre-printed Tickets: Completed by Front office staff
Advantage/Request Tickets: Completed by Clinicians
11- Office
12-Home
21-Inpatient Hospital
22-Outpatient Hosp
23- Emergency Room (Hosp) 51-Inpt Psych Facility
53-Community MHC
99-Other
03-School (when not Medicaid)
F.
Injectables:
Nurse writes in name of medication administrated
G.
MGs:
Nurse writes in dosage of medication administered
H.
Group Number: Assigned by front office staff for all group type services
I.
Number in Session: Clinician completes number of clients in the session for all services.
Client shows=1
Client no shows=1 but C/S space should have a code entered for the type of cancellation
Groups= the number of clients that actually attended the group session
J.
Cost Center: Leave blank
K.
TPL: Only affects those services that are billable to both Medicare and Medicaid but are being billed to
Medicaid for one of the following reasons: Remember that you must be eligible to provide the Medicare
service i.e. have the correct credentials/license.
1- Physician not on premises
2- Service provided away from the Center
3- Second billable service on the same day
4- Not credentialed to provide Medicare service
L.
Doctor on premises:
If service is a PMA, list the staff number of the physician providing the service
Services other than PMA list the On-Duty physician’s staff number. This can be any physician on the
premises.
If there is no physician located on premises list “0” in the space.
M.
Incarcerated (Y/N): DO NOT LEAVE BLANK
Y=Client incarcerated
N=Client not incarcerated
N.
Emerg/Afhrs: Write in the applicable code of when client was seen
0- No Emergency/Normal work hours
2-Emergency/Normal work hours
1- No Emergency/After work hours
3-Emergency/After work hours
31
O.
Problem: Indicates problem of particular session
0 – Psychiatric
3 – Psychiatric/MR
1 – Substance
4 – Psych/Substance/MR
2 – Psychiatric/Substance
5 – Substance/MR
6 – All others
P.
RX Doc: Staff ID# of the physician who prescribed meds for that service
Q.
Prescriptions: Number of prescriptions that visit
R.
Refills: Number of refills given that visit
S.
Staff ID: Write in the staff ID# for each staff rendering service
T.
SVC Time: Write in staff time for each staff rendering service. Service Time must be less than or equal
to bill time.
U & X.
Next Appt. Time: Write date, time and length of next appointment
V.
Staff Signature/Title: Primary Clinician must sign full name and title.*SPD must have physician’s
signature as well. If another clinician writes the note that clinician must sign what they have written.
W.
ID#:
Y.
Date: Write in the date of service if not pre-printed by computer/scheduler.
Z.
Svc Code: Write in the CIS code for service rendered.
AA.
Desc: Write in the HHS approved abbreviation description of the service rendered
BB.
Can/NS: Leave blank if a service was rendered. Cancellation/No Show codes are:
1 – No Show
2 – Client Cancelled
3 – Client Rescheduled
4 – Therapist Cancelled
5 – Therapist Rescheduled
CC.
Bill time:
Write in all actual time during which a service was rendered
DD.
CID:
Write in client’s identification number if not already present on ticket
EE.
Name:
Write in client’s first name and last name- not a nickname.
ID# of primary clinician
Scan in a ticket.
32
SECTION 5
FEE STATUS AND BILLING REQUIREMENTS
Clients at the Center are billed on their ability to pay based on income and the number of people dependent on
that income. This is determined at the time of the first visit based on proof of income that the client must
provide. The fee status is reviewed annually and whenever the client reports a change in any of the factors
which determine fees. Completion of the forms when fee status changes or annual updates is the responsibility
of the administrative and clinical staff. The initial fee sheet is the responsibility of the administrative staff
member completing the ID Data sheet.
Special Documentation Requirements
1.
The following services may be billed to Medicare, if the clinician is credentialed to provide them. All
others must be billed to other payors.
a.
Individual Therapy
b.
Group Therapy (A maximum of 60 minutes is allowed without justification. If justification is
included, 90 minutes may be billed.
c.
Medication Monitoring
d.
Psychiatric Medical Assessment (PMA)
2.
Services cannot be billed to MEDICARE if there is no physician on premises. If at all possible, schedule
Medicare clients only on days when there is a physician present on premises.
3.
When a client has insurance, the insurance company is billed first. If more than one insurance is to be
billed, the second insurance is not billed until payment is received from the first. Then the remainder of
the bill is submitted to the secondary carrier. When all insurance payments have been collected, the
client is billed for the remainder of the bill unless assignment has been accepted. The client is
responsible for all or a portion of the remaining fees. (This depends upon the income and number of
dependents on the income.)
4.
Payment (or non-payment) of fees is a treatment issue. Clinicians need to help the client accept
responsibility for their treatment, which includes being responsible for the bill.
5.
Clients who are incarcerated cannot be billed for any services. However, if they are out on bail, bond, or
parole; they can be billed.
33
SECTION 6
CHANGE FORMS
Change forms are done at any time during treatment when the client’s vital statistics, such as address,
phone number, case manager, etc., change. Client information must be updated every 6 months for
CIS.
Case Managers receive a report to remind them of the needed form to be submitted.
See next page for a copy of the change form.
34
BCMHC CHANGE FORM
__________________________________________
Client Name Last, First, MI
______________________________
CIS Client#
ONLY COMPLETE BLOCK THAT APPLIES TO NEW INFORMATION
New
__________________________________________________________________________________________________
Address
__________________________________________________________________________________________________
Living Arrangement ____________ Household composition ________ (must update if address changes)
*If admission to or discharge from a hospital, address does not have to change unless discharged to a different place.
Is the consumer receiving a housing rent subsidy? Y N
If Yes, indicate the type of rent subsidy:(9)
_____ Public housing project _____ Tenant based Section 8 rental assistance ____ Shelter Plus care ___ Section 8 applied
____ Section 8 applied for and rejected Why? ___ Criminal Hx ___ Poor hx with landlord ___ Other
____ Section 8 rental assistance not available ___ Not applicable
H _______________________
Phone
New Insurance
W_________________ Cell _______________________
Co Name_________________________________________________________
Address__________________________________________________________
__________________________________________________________
Policy #_____________________Holder_______________________
New Diagnosis
1st__________ 2nd__________ 3rd___________ V___________
Answer Yes or No to each question in the applicable section (SMI or SED)
SMI (adults) Y N Planned or attempted suicide within the last 12 months
Y N Lacked legitimate productive role
Y N Impairment in main productive roles, consistently missing one full day of work per month
Y N Serious interpersonal impairment, socially isolated, lacking intimacy and social support.
SED (kids)
Y N Interferes with child’s role or functioning in family, school, or community
Y N Difficulties in achieving or maintaining one or more developmentally appropriate skills
Y N Impairments episodic, recurrent, or continuous other than those temporary responses to stressful events in envir.
Y N Met this criteria during year without benefit of treatment or support services.
New Employment Status: _____ Employment Date: _________________
Date Terminated: _________________
Employment Level: _____ Wages: __________
Correct Name to: _____________________________________________________
Type of Commitment: ______________
Date of Court Order: _______________
NEW PHYSICIAN ID#:___________
New Casemanager: __________Must also provide new location and office code
New Location Code: __________
Office Code: __________
Other:_________________________________________________________________
GAF/CGAS Score: ________________
Date of GAF Score: _______________
Next of Kin:_____________________________________________________________
Address:__________________________________________________________
Phone: Home________________ Work:___________________ Cell:__________
Clinician Submitting Change Form: __________
Date:______________________
35
Rev.03/15/05
SECTION 7
BILLING ERROR CORRECTION PROCEDURES
1.
Staff person identifying the billing discrepancy completes the BCMHC Internal Billing Discrepancy
Form.
2.
The form, along with the medical record, is reviewed with the respective supervisor to review the nature
of the discrepancy and/or documentation deficiencies that may be identified in the medical record.
EXCEPTION: In the case that the discrepancy is identified by QA or UR staff, supervisory review is not
necessary.
3.
The Billing Discrepancy Form is forwarded to QA for further review and authorization for billing
adjustments. Any additional notes may be added to assist billing staff in understanding the nature of the
required billing adjustments. Authorized billing adjustments may include:
¾ No reviewing physician’s signature and date on ITP to confirm medical necessity
and appropriateness
¾ Discrepancy in service code or definition
¾ Discrepancy in bill time
¾ No record or documentation of service
¾ Clinical service notes do not substantiate that the service billed was rendered
¾ Billing for more frequent services than were ordered on the ITP
¾ Service rendered is not listed on treatment plan
¾ Service rendered was added after the physician signed the ITP and has not been
signed off by doctor (initial/date)
¾ PMA not rendered within time limits on admission
¾ Voided tickets for any reason
¾ CSN not signed/dated by clinician
4.
QA forwards Billing Discrepancy Form to billing staff who adjusts accounts accordingly.
5.
Once billing adjustments are made, total dollar adjustments are calculated and reported to QA. QA is
responsible for routing this information to Executive Director, Supervisory Team, DMH Office of
Quality Management, and DHHS per department guidelines.
36
BCMHC INTERNAL BILLING DISCREPANCY FORM
CLIENT:
CID #:
DATE:
REVIEWER:
FUNDING SOURCE___________ Medicaid
Ins
___________ Medicare
Champus
____Self-Pay
____Private
PLEASE COMPLETE THE FOLLOWING:
DATE OF
SERVICE
TICKET #
STAFF/
PROVIDER
(NAME)
STAFF/
PROVIDER
(ID#)
REASON FOR
BILLING ERROR
SERVICE
CODE
(use discrepancy
key)
TOTAL $
ADJUSTMENT
(Billing Staff
Use Only)
TOTAL
ADJUST.
(billing use
only)
Discrepancy Key
A. Void Ticket - Specify: _____________________________________________________________________________
B. No reviewing physician’s signature and date on individual treatment/service plan to confirm medical necessity and appropriateness.
C. Discrepancy in service code/definition. Specify ______________________________________________________________
D. Discrepancy in bill time. Specify : ____________________________________________________________________________
E. No record or documentation of service.
F. Clinical Service notes do not substantiate that the service billed was rendered.
G. Billing for more frequent services than were ordered on the Individual Treatment/Service Plan.
H. Service rendered is not listed on the Individual Treatment/Service Plan.
I. PMA not rendered within the first 90 days of admission
J. Other: (Specify) _______________________________________________________________________________________
_______________________________________________________________________________________________________
BILLING CORRECTION AUTHORIZATION (All forms require signature of supervisor)
Signature
Date
Supervisor
_________________________________
__________________________
QA/UR
_________________________________
__________________________
Billing
__________________________________
___________________________
Billing to QA
__________________________________
_____________________________
rev.12/99
37
SECTION 8
MEDICAL RECORDS SIGNATURES AND INITIALS/LEGIBILITY
Signatures include name, title, and date.
Initials include date.
Signatures are necessary for any entry in the medical record. All forms and Clinical notes require the
clinician’s signature. If a clinician fills out the billing ticket and signs the front sheet and another clinician
writes the service note, that clinician must also sign and date their entry. Any addition to a note, POC, progress
summary, etc., must be signed and dated by the clinician adding the entry.
Initials are acceptable for error corrections anywhere in the chart. A physician may initial additions to the POC
(services added) along with the date of the initialing.
Titles
In the interest of uniformity, titles should be listed as your educational degree and/or license.
Example: Cathy Parker, M.Ed., LPC
Barbara Nelson, RN
Black ink is to be used for documentation unless otherwise specified for a particular situation.
All clinical documentation must be typed or legibly written. If you have a “distinctive” signature, print your
name beside/under the signature.
Photocopied, stamped, or computer generated signatures, or signatures of anyone other that the person
rendering the service and/or co-signature, when required, are not acceptable
38
SECTION 9
MEDICAL RECORDS ORGANIZATION
All sections are described from TOP TO BOTTOM.
SECTION I
1.
Discharge Data (if closed)
2.
CIS Facesheets
3.
Fee Sheets
4.
Financial information - copies of insurance info, etc.
5.
Voters Reg. Form
6.
Consent forms (audio/video, consent to treatment, consent to follow up, etc.)
7.
Orientation page (Client signs for orientation package)
8.
Proof of income, copies of insurance, driver’s license, etc
SECTION II
1.
Accounting Log (M453)
2.
Post Discharge follow-up letter (if closed)
3.
Court Orders of Dismissal (should always remain on top if applicable)
4.
Court Orders/Judgements (should always remain on top with identifier on front of chart)
5.
Letter to Amend (M452) with Center response by date requested
6.
Letter to Inspect/Copy(M451) by date requested
7.
Desire for Treatment Letter
8.
Correspondence ("Correspondence" chart divider if applicable)
(all items in chronological order)
A.
Court Correspondence
B.
Desire For Treatment Lettes
C.
Appointment Letters/No-show Follow-up Letters
D.
Authorization for release of information
E.
Business Correspondence
F.
School Reports
G.
Boarding Home/Nursing Home Notes
H.
Miscellaneous treatment information from outside sources
I.
*(Chart Divider for Conners Forms) Children Only*
9.
("Hospital" chart divider)
Hospital Summaries (and commitment papers)
Hospital summaries and corresponding commitment papers must be filed together with no other information
between them.
SECTION III
1.
Confidential Information Sheet (Teal sheet, if applicable, with chart notifier on outside of chart)
2.
Physicians Medical Assessment Notes
(Medication Education/Consent Sheets Divider)
3.
Neuroleptic Consents, Medication Information sheets
(“AIMS” Chart divider)
4.
Testing Materials and Results (AIMS Scale,etc.)
5.
Weight Chart, if necessary
("Lab/X-Ray" chart divider)
6.
Lab Results
(Nurses notes divider)
7.
Medication monitoring notes
("Injection Record" chart divider)*Only for clients receiving injection
7.
Injection (MAR) Record
(“Medications” chart Divider)
8.
Prescription Copies mounted on prescription sheet in order
SECTION IV
1.
Discharge Plan/ Summary (if closed)
2.
POC with Progress Summaries- Transition plans if applicable
3.
Outcomes Measures (Adult Outcomes Form, CBCL)
4.
Care Plan (Boarding Home Patients only)
5.
TCM section divider to include TMC Plan, progress summaries and CSNs.
6.
IPS chart divider (if applicable)- all assessments and material related to IPS program
7.
(SCIMA chart divider, if applicable)
assessment tools for SCIMA-schizophrenia only
("Progress Notes" chart divider)
39
8
.9
.10
11.
12.
13.
14.
Clinical Service Notes including generic notes in chronological order
(Crisis/Brief Assessment Divider)
All crisis/brief assessment forms
(Divider for Assessment information)
Hospital Discharge Assessment
Initial Clinical Assessment
Medical Assessment
Trauma Assessments
Intake Sheet
SECTION V AND VI (Only for PRS)
1.
PRS notes to correspond to CSN in Part IV in chronological order (most recent on top)
At any place in the chart, a properly labeled "blank" chart divider may be included.
Rev. 4/03
4088
SEPARATING CHARTS
When a chart has gotten too thick to easily handle, or information is awkward and difficult to find, information is
separated into two charts (or more as the case may be.) Notify the medical records clerk to separate the chart.
To follow is a guide for your understanding of how this process is accomplished and where you should look for
information once the chart has been divided. It is a logical process. The basic idea is that all information which is related
to a particular ITP moves with that ITP.
1.
An ITP is closed for a guide in separating a chart.
2.
The ITP is removed and any information from the time period which it covers as indicated below. Unless
otherwise indicated, move original documents to the new chart.
a.
Clinical service notes - Keep the CSN's in the chart with the correct ITP.)
i.
It is determined whether it will be easier to remove CSN's from the Data
Mount Sheet which should go into the new chart or remain with the old chart.
ii.
Appropriate CSN's are careful removed and placed on a new Data Mount Sheet.
iii.
Generic notes are written to place in both charts to indicate that CSN's were moved
in the process of thinning the chart, and indicates that the rest of the CSN's may be found in
another chart.
b.
Miscellaneous notes
c.
Weekly summaries
d.
Physician's notes
e.
Injection record
f.
The neuroleptic consent form
g.
Prescription copies
h.
Laboratory work reports
i.
Correspondence, both in and out of the Center
j.
Any change in diagnosis forms for the time period covered
k.
The ID Data and Consent forms for the CURRENT admission
l.
Any other information not specified above which in considered necessary for comprehensive care
m.
The Clinical History & Evaluation for the CURRENT admission
For items b, c, d, e, and l it may be necessary to make copies to provide uninterrupted flow of information in both
charts. This is accomplished by copying each page (front and back) of information which needs to be moved to a new
chart and contains information which goes with an ITP in the original chart. Copies are clearly marked as such. Copies
and originals are placed in the charts in the manner which will best suit the ITP.
Torn or weakened pages are strengthened with reinforcements or tape. Parts I and II are filed in separate holding.
In addition to the regular labels, multiple part charts need to have an additional label. It should be on both the original chart as
well as any and all supplemental charts which are made. These are placed on the front of each chart on the upper right side.
FOR EXAMPLE:
John Smith
John Smith
00000
00000
PART I
PART II
1/1/81 - 7/1/87
7/1/87 Micro filmed Part I and II’s are kept at least 3 years at the center.
41
Section 10
CORRECTING DOCUMENTATION ERRORS IN THE MEDICAL RECORD
DOCUMENTATION ERRORS:
1.
2.
3.
NEVER use white out or any type of correction tape. This can be interpreted as falsification of medical
records.
Never completely scratch through an error. This applies to “write-overs” as well.
The proper way to correct an error is:
a. Draw one line through the error/mistake, Write “ME” (mistaken entry).
b. Initial and date the mistake.
c. Continue writing immediately following the mistake.
42
Section 11
CONFIDENTIALITY/PRIVACY ISSUES
SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina
OFFICE OF THE STATE DIRECTOR OF MENTAL HEALTH
TO:
All Employees
SUBJECT:
Privacy Practices
DIRECTIVE NO. 837-03
(1-040)
Purpose
This Directive describes DMH policy for the use and disclosure of DMH Consumer medical
and payment Protected Health Information or “PHI” (see Notice for terms that begin with a
capital letter) and Consumer rights related to access, control, accounting and amending of
their PHI. This Directive incorporates DMH Form M-010, “NOTICE OF PRIVACY
PRACTICES” (“Notice”), as well as other forms and procedures listed in the Appendix.
Appendix components are identified in this Directive by quotes and caps (e.g.
“AUTHORIZATION TO DISCLOSE SCDMH PROTECTED HEALTH INFORMATION”). This
Directive includes future Notices, forms or procedures added to the Appendix, and adopted
in accord with DMH policy and applicable law.
Each DMH employee, volunteer or other person (e.g., contract physician) incorporated in
the DMH workforce (“workforce member” or “staff”) and officials, must sign
acknowledgement of receipt of, and agreement to comply with this Directive. The signed
statement must be kept in the applicable personnel or other official folder. Each DMH
component must ensure training of its staff consistent with this Directive and DMH Privacy
Practices training. All DMH component policies or agreements must be consistent with this
Directive.
Applicable Law
This Directive is to conform with, and is subject to, applicable federal and state law,
including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
Section 44-22-100 of the Code of Laws of South Carolina. Identifying information from
alcohol and drug treatment programs is subject to additional restrictions and protections
under federal law 42 CFR Part 2. If in doubt as to whether 42 CRF Part 2 applies to a DMH
program, the applicable local director should consult with the DMH Office of General
Counsel. In general, DMH is required by law to: follow the Notice requirements; keep
Consumer information private; give Consumers the opportunity to review the Notice and
request restrictions on PHI use or disclosure; not use or share PHI without Consumer
Authorization except as described in the Notice; provide for Consumer rights involving
control over his or her PHI; and a procedure for Consumer complaints about DMH privacy
practices.
Additional requirements (e.g., for licensing, accreditation, etc.) may also apply to individual
43
DMH components.
1) Notice
A copy of the current DMH Notice must be posted at each service site where persons
seeking DMH services will be able to read it. When DMH changes the Notice, a current
copy must be posted in like manner. A copy of the Notice must also be posted on the DMH
Internet Web site. Consumers must have the opportunity to review the Notice and receive a
paper copy at any time. DMH service sites must attempt to obtain a Consumer’s signed
acknowledgement of receipt of the Notice at the Consumer’s next visit beginning April 14,
2003. This acknowledgment is to be recorded on DMH Form C-107 (revised March, 2003)
“CONSENT TO EXAMINATIONS AND TREATMENT” or an applicable intake or admission
form, containing the statement (or an attached statement):”I have been provided a copy of
the SCDMH Notice of Privacy Practices and an opportunity to review it and ask questions.”
If not signed, staff must note on the signature line of the statement, why signed
acknowledgement was not obtained (e.g., “refused a copy of the Notice”, “refused to sign”,
etc.) Questions concerning the Notice, this Directive, or DMH Privacy Practices should be
directed to the local Privacy Officer or the DMH Privacy Officer.
2) DMH Uses and Disclosures of PHI
After providing the Consumer with the opportunity to review the Notice, and object and/or
request certain restrictions, staff may share PHI as described in the Notice. In an emergency
or if the Consumer is incapacitated, without giving the Consumer the opportunity to review
the Notice, object or request limitations, DMH may use and/or share PHI as permitted under
the Notice. As soon as reasonable after the emergency or incapacity, the Consumer must
be given those opportunities. When practical and when it will not compromise Treatment,
DMH should accommodate a Consumer’s request to limit PHI use or disclosure. As
described in the Notice, PHI may be disclosed pursuant to a Business Associate
Agreement, approved by the DMH Contracts Office and the DMH Privacy Officer. DMH
workforce members should limit use or disclosure of PHI to the Minimum Necessary to
accomplish the purpose for the use or disclosure as described in the Notice.
For use and disclosure of PHI for Operation purposes, applicable component directors must
identify employees who need access to PHI to carry out their DMH duties (see Notice); and
the PHI categories to which access is needed and any limitations to such access. For types
of disclosure of, or request for, PHI made on a routine and recurring basis, the component
must implement protocols limiting the PHI disclosed or requested to the Minimum Necessary
to achieve the purpose of the disclosure or request. Protocols must be reviewed and
approved by the local Privacy Officer. For other PHI disclosures or requests (i.e., nonroutine, non-recurring), the component must develop protocols to limit the PHI disclosed or
requested to the Minimum Necessary and review all such requests for disclosure on a case
by case basis to determine that the PHI information sought is limited to the Minimum
Necessary to achieve the purpose of the specific disclosure or request.
3) Other Exceptions, Legal Proceedings, Notice of Privacy Law
Unless disclosure is otherwise permitted by the Notice, upon receipt of a subpoena or other
request for PHI, a statement substantially similar to the “MODEL NOTICE OF PRIVACY
LAW” must be sent to the requester. If required to provide testimony or other information
containing PHI in a legal proceeding, staff must follow the procedure described in
“DISCLOSURES IN LEGAL PROCEEDINGS.”
4) Authorizations
44
Unless permitted by the Notice, PHI may not be disclosed without a signed
“AUTHORIZATION TO DISCLOSE SCDMH PROTECTED HEALTH INFORMATION”, to be
kept in the Consumer’s medical record. Requests pursuant to an Authorization must be
acknowledged within 15 days of receipt and completed within 60 days.
5) Re-Disclosure Notice
When PHI is authorized to be disclosed by the Notice (e.g. photocopies of a medical records
sent to a non-DMH medical provider for Treatment), the disclosed copies of PHI must be
accompanied by a notice cover sheet or other statement substantially similar to the “MODEL
NOTICE PROHIBITING RE-DISCLOSURE.”
6) Consumer Privacy Rights
The Notice describes the following Consumer PHI privacy rights: receipt of a copy of the
Notice and opportunity to review and ask questions; object and request restrictions on some
PHI uses or disclosures; request confidential communication/notification; inspect and obtain
copy of PHI; request amendment to PHI; receive an accounting of PHI disclosures; and the
right to file a complaint with DMH, HHS and Office of Civil rights about DMH privacy
practices. As described following, exercise of Consumer privacy rights concerning his or her
PHI, may require that a Consumer complete a written request and follow the noted
procedure. Formal Privacy Practice complaints may involve the Privacy Officer and the
Consumer Advocate.
7) Consumer Access to His or Her Own PHI, Psychotherapy Notes
A Consumer has the right to request (“REQUEST TO INSPECT AND/OR COPY SCDMH
PROTECTED HEALTH INFORMATION”) access and/or copies of his/her PHI as described
in the Notice as long as DMH maintains the PHI. The applicable component must document
and retain for 6 years, Designated Record Sets subject to Consumer access and titles of
persons and/or offices responsible for processing access requests. The DMH component
must act on a Consumer’s request as described in the Notice, but may deny access to some
information including Psychotherapy Notes as described in the Notice. Note the narrow
definition of Psychotherapy Notes in the Notice. All DMH Treatment and Payment
information should be kept in the applicable DMH record. If a member of the DMH
workforce keeps Psychotherapy Notes, he or she does so as an individual, and is therefore
individually responsible for their content, control, protection, access and disclosure,
including disclosure pursuant to a court order or as otherwise required by law.
As applicable, the DMH component must inform the Consumer that the request has been
granted and provide access as requested (see “MODEL REPLY TO REQUEST TO
INSPECT AND/OR COPY”). PHI should be provided in the format requested if readily
reproducible or in readable hard copy or other format as agreed to by the Consumer, unless
he or she agrees to a written summary as described in the Notice. If the same PHI is
maintained in more than one Designated Record Set or at more than one location, the PHI
may only be produced once. If the component does not maintain the requested PHI, but
knows where it is maintained, the component must inform the individual where to direct the
request.
If access is denied, the DMH component must provide a written denial within 15 days of the
request (see “MODEL REPLY TO REQUEST TO INSPECT AND/OR COPY”). If the
Consumer requests a review in writing, the component must designate a licensed health
care professional who was not involved in the denial decision to review the denial. The
designated person must give the Consumer written notice within 15 days of review request,
45
the designated person’s decision, and take other action necessary to carry out the decision.
8) Consumer’s Right to Request Amendment to PHI
After a Consumer requests an amendment in writing (“REQUEST TO AMEND SCDMH
PROTECTED HEALTH INFORMATION”) staff must act on the request in accord with the
Notice timelines and procedures. The request must be forwarded to the component director
with copy to the local Privacy Officer. The director must designate staff to review the
request and take needed action documented on Page 2 of the “REQUEST” form. The
request must be reviewed by the designated staff in conjunction with staff originally
recording the PHI and by the staff’s supervisor(s), who must consult with other staff as
needed to determine if an amendment is needed. Any conflict must be resolved by the
director. The Consumer must be informed of the final decision by a letter substantially
similar to the “MODEL REPLY TO REQUEST TO AMEND” with a copy of the original
“REQUEST”, including Page 2 documenting the DMH component’s review and basis for its
decision.
If the request for amendment is approved, after notifying the Consumer as noted above and
obtaining the Consumer’s agreement with the proposed amendment, the amendment should
be made, the record flagged to indicate the amendment and the amendment form filed in the
record. Staff should also attempt to secure the Consumer’s permission to notify necessary
relevant persons of the amendment. If the Consumer refuses, document the attempt to
obtain permission in the record prior to giving needed notification.
A request for amendment may be denied if the PHI: was not created by DMH; is not in the
Designated Record Set; or the PHI is accurate and complete. If the request is denied, the
Consumer must be notified in writing as described above indicating: the basis for the denial;
that the Consumer may submit a one-page written disagreement, stating the basis for
disagreement; that the Consumer may request that future disclosures of the disputed PHI
include the request and the denial; and how the Consumer may file a Complaint.
Records must be maintained identifying the PHI in the Designated Record Set that is the
subject of the disputed amendment and appended or otherwise linked to the Consumer’s
request for amendment, DMH denial, Consumer’s statement of disagreement, and any DMH
rebuttal. If a Consumer submits a statement of disagreement following a denial, subsequent
disclosures of the disputed PHI must include the above items.
9) Consumer’s Right to Request Accounting of Some PHI Disclosures
DMH components must log each applicable PHI disclosure using the “ACCOUNTING LOG
OF PHI DISCLOSURES”. The accounting must include disclosures by DMH as well as
disclosures to a DMH Business Associate. This accounting requirement does not include
PHI used or shared before April 14, 2003 or other disclosures described in the Notice. The
local Privacy Officer or designee must respond to a Consumer’s written request, and
provide, a copy of the applicable accounting log as described in the Notice (see “MODEL
REPLY TO REQUEST OF ACCOUNTING LOG”). However, a Consumer’s right to receive
an accounting log must be suspended if a health oversight agency (HHS) or law
enforcement official notifies DMH that providing an accounting would be reasonably likely to
impede the health oversight or law enforcement agency’s activities and specifying the time
for which the suspension is required. DMH must document that statement (including the
identity of the agency or official) and temporarily suspend the Consumer’s right to an
accounting for no longer than 30 days, unless a written statement is received from the
applicable agency during that time.
46
10) Consumer Privacy Practice Complaints
Applicable DMH components must, in coordination with the local Privacy Officer and
Consumer Advocate, have a process for Consumers to make a written complaint about
DMH privacy practices or compliance with those practices (“SCDMH PRIVACY PRACTICES
COMPLAINT”) and must document all complaints received and their disposition as
described in the Notice. At any time, a Consumer has the right to file a complaint with DMH
and/or HHS as described in the Notice. DMH must provide records and compliance reports,
as required by HHS and otherwise permit access, as requested by HHS, to applicable
facilities, records, and other sources of Information, including PHI as needed for a HHS
inquiry or investigation pursuant to a Complaint.
DMH component or staff may not intimidate, threaten, coerce, discriminate against, or
retaliate against any person for the exercise of rights or participation in any process relating
to this Directive, or against any person for filing a complaint with DMH, HHS or other privacy
related investigation, compliance review, proceeding or hearing, or engaging in reasonable
opposition to any act or practice that the person in good faith believes to be unlawful under
HIPAA or state law as long as the action does not involve disclosure of PHI in violation of
the regulations, nor require individuals to waive any of their rights under HIPAA or state law
as a condition of Treatment or eligibility for DMH services.
11) DMH Privacy Officer:
DMH must designate a DMH Privacy Officer responsible for the development and
implementation of DMH privacy practices. Applicable DMH components must designate a
local Privacy Officer and Privacy Practices workgroup that advise and support the local
Privacy Officer and DMH Privacy Officer.
12) Training:
DMH components must document training on DMH Privacy Practices before April 14, 2003
for its workforce members. Each new workforce member must receive this training within 30
days after joining the workforce. Each workforce member, whose functions are impacted by
a material change in this Directive, or by a change in position or job description, must
receive the training as described above within a reasonable time after the change becomes
effective. All training must be documented and records retained for 6 years.
13) Sanctions and Mitigation of Damages
DMH Human Resources office must document and each DMH component must apply,
appropriate DMH employee disciplinary action, for employees who fail to comply with this
Directive. Exceptions include disclosures made by employees as whistleblowers, for
mandatory reporting or certain crime victims. Each DMH component must have a process
to mitigate, to the extent practicable, any harmful effects of unauthorized uses or disclosures
of PHI by the component or any of its Business Associates.
14) Security
Applicable DMH components must comply with “PRIVACY PRACTICES SECURITY”
requirements.
15) Documentation Requirements:
Applicable DMH components must maintain Directive policies and procedures in written or
electronic form as well as written or electronic copies of all communications, actions,
47
activities or designations required to be documented by this Directive, for 6 years from the
later of the date of creation or the last effective date.
16) Disclosure of Unidentifiable Information or Information in Limited Data Sets
PHI may be disclosed under the requirements and protocols described
“UNIDENTIFIABLE OR DE-INDENTIFIED INFORMATION” or “LIMITED DATA SETS.”
in
17) Charges for Copying and Other Expenses Related to Copying and Access to PHI.
As permitted by this Directive, PHI may be disclosed by photocopy or fax. A fee to cover
costs of reproducing may be charged and collected in advance of providing copies in accord
with DMH Regulation 87-4(D): “The first fifteen copies will be provided at no charge;
beginning with the sixteenth copy, there will be a fee of twenty cents per page. If a request is
made for records which are not readily available, the Department may determine a
reasonable hourly rate for the expense of searching for and securing such records. The
Department may also require a reasonable deposit for such anticipated expense from the
person making the request prior to searching for or making copies of the records. “
18) Violations and Penalties
All violations of this directive must be reported to the applicable person's supervisor. DMH
employees who make an unauthorized disclosure of PHI, or otherwise violate provisions of
this Directive, are subject to disciplinary action in accordance with the DMH Employee
Discipline Directive. Further, South Carolina law provides for penalties for the unauthorized
disclosure of PHI up to one year imprisonment and/or a fine of up to $500. Federal law
provides for penalties of $100 per incident up to $250,000 and ten years in prison.
Unauthorized use or disclosure of PHI may also subject the employee to additional civil or
criminal liability.
This Directive with referenced “Notice of Privacy Practices” and Appendix, replaces the
DMH Directive No. 771-92 “Confidentiality of Medical Records and Patient Information.”
This Directive is effective April 14, 2003.
48
PRIVACY PRACTICES SECURITY
Applicable DMH components must be assessed for security of PHI that it receives, creates, maintains or
discloses, twice per year initially and annually thereafter by designated component staff. Problems identified
during the assessment will be reported in writing and include a corrective action plan with a copy provided to
the local Privacy Officer for follow up and resolution. Reasonable efforts will be made to mitigate and correct
identified problems. Unresolved problems must be reported to the DMH Privacy Officer.
General Guide For Copying, Faxing Or E-Mail Of Protected Health Information
1) Post a sign near copy/fax machine similar to the following: “All paper containing Protected Health
Information that is no longer needed, including extra copies or sheets that are copied incorrectly, must be put
in the recycle bin face down so that it may be shredded.”
2) Information disclosed should generally be the minimum necessary to accomplish the intended permitted
purpose. This usually means limiting the scope and content of information requested, used or disclosed.
However, complete identifying information may be necessary for Treatment purposes.
3) For fax cover sheets and e-mail subject matter title and messages referring to a Consumer, unless
essential for the understanding of the message (identifying detail may be needed for Treatment, if there is a
likelihood of confusion, etc.), de-identify or otherwise limit the identity of the Consumer (e.g., “41yr.old male
admission last night”; strike through the name; Consumer‘s first name and last initial only, “Ferris B.”, etc.).
4) Double check phone/addresses prior to sending faxes or e-mails.
5) Only send to DMH staff who need the information in doing their DMH job.
6) Do not leave PHI documents at the copy/fax machine once the information has been copied or faxed,
7) Fax and e-mail communications or transmissions that include PHI should identify the intended recipient, the
sender (with reply contact information) and include a notice statement substantially similar to the following:
PRIVACY NOTICE: THIS COMMUNICATION IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY
TO WHICH IT IS ADDRESSED AND MAY CONTAIN SCDMH PATIENT OR OTHER INFORMATION, THAT IS
PRIVATE AND PROTECTED FROM DISCLOSURE BY APPLICABLE FEDERAL AND/OR STATE LAW. IF THE
READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT OR RESPONSIBLE FOR DELIVERING
THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION,
DISTRIBUTION OR COPYING OF THIS COMMUNICATION OR THE INFORMATION CONTAINING WITHIN IT,
IS STRICTLY PROHIBITED AND MAY SUBJECT THE VIOLATOR TO CIVIL AND/OR CRIMINAL PENALTIES.
49
IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY US IMMEDIATELY BY
TELEPHONE, REPLY E-MAIL OR FAX USING THE PHONE NUMBER OR ADDRESS INDENTIFIED IN THIS
COMMUNICATION AND DESTROY OR DELETE ALL COPIES OF THIS COMMUNICATION AND ALL
ATTACHMENTS.
LIMITED DATA SETS
When using or disclosing PHI, a DMH component may use a limited data set if the
component enters into a data use agreement with the limited data set recipient providing
that a limited data set not include any of the following direct identifiers of the individual who
is the subject of the PHI or of relatives, employers, or household members of the individual:
Names; Postal address Information, other than town or city, State, and zip code;
Telephone numbers or Fax numbers or Electronic mail addresses;
Social security numbers or Medical record numbers;
Health plan beneficiary numbers or Account numbers;
Certificate/license numbers;
Vehicle identifiers and serial numbers, including license plate numbers;
Device identifiers and serial numbers;
Web Universal Resource Locators (URLs) or Internet Protocol (IP) address numbers;
Biometric identifiers, including finger and voice prints; or
Full face photographic images and any comparable images.
A DMH program area may use or disclose a limited data set only if it obtains satisfactory
assurance, in a memorandum of agreement, that the limited data set recipient will only use
or disclose the PHI for limited purposes. The memorandum of agreement must:
Establish the permitted PHI uses and disclosures in the limited data set by the recipient;
Establish who is permitted to use or receive the limited data set;
Provide
that
the
limited
data
set
recipient
will:
Not use or disclose the Information unless permitted by the agreement or as required by
law;
Use
appropriate
safeguards
to
prevent
improper
uses
or
disclosures;
Report any known use or disclosure not provided for by its data use agreement;
Ensure that any agents, including subcontractors, to whom it provides the limited data set
agrees to the same restrictions and conditions that apply to the recipient with respect to the
PHI;
and
Not attempt to identify or contact the individuals whose data are included in the limited data
50
set.
A DMH program area may use or disclose a limited data set only for the purposes of
research, public health, or health care Operations. If the limited data set is needed for
research or projects that have a research component, DMH’s Institutional Review Board
(see Research policy) must approve the research project.
The DMH program area that will use or disclose the requested limited data set must
determine the purpose of the request. If the request is for research purposes or has a research
component, DMH’s Institutional Review Board must first review the request. If the
Institutional Review Board approves the research, the Institutional Review Board
Administrator will inform the program area that it may proceed with the memorandum of
agreement as described in this policy. If the purpose of the limited data set is for public
health or health care Operations, then the DMH program area may proceed with the
memorandum of agreement as described in this policy. The DMH Privacy Officer or his/her
designee must approve the memorandum of agreement before the limited data set is provided
to the requestor.
MODEL NOTICE OF PRIVACY LAW
[LETTERHEAD]
[DATE]
[NAME]
[FAX/ADDRESS]
In reply to your subpoena or other request dated _________________, pertaining to ___________________:
Please take notice that Information identifying a patient or former patient of the South Carolina Department of
Mental Health (SCDMH) or a person for whom civil commitment has been sought, is protected by §44-22-100,
Code of Laws of South Carolina, as amended, and 45 CFR Part 160 (HIPAA). Such Information may not be
disclosed (oral, written, or otherwise) except as authorized under HIPAA and §44-22-100, including written
Authorization meeting requirements of those laws, or a South Carolina or federal court order pursuant to
Section 44-22-100 (A)(2), finding that “disclosure is necessary for the conduct of proceedings before it and that
failure to make the disclosure is contrary to public interest.” Individual patient Information may be further
protected by other law, including alcohol and drug treatment records protected under 42 CFR Part 2. General
authority to disclose Information including: subpoena for records or testimony; discovery order; workers'
compensation claim; foreign court order or general consent, is usually not sufficient to authorize disclosure of
such information. Unauthorized disclosure is subject to civil and criminal penalty.
A copy of the SCDMH Authorization form is attached. When the applicable Authorization or court order is
secured meeting requirements of Section 44-22-100 (A) (2), you may then send a copy with the request or
subpoena for the release of the applicable information. If the Authorization is signed by a person other than
the patient, also attach a copy of the document authorizing substitute consent (e.g., court appointment as
guardian, personal representative, etc.)
If you believe that some other exception under the above noted laws otherwise permit or require disclosure, let
us know. As applicable, should the attorney handling this case have any questions concerning the applicable
law or court order, please contact the Office of General Counsel, South Carolina Department of Mental Health,
P. O. Box 485, Columbia, South Carolina 29202; voice # 803.898.8557, fax # 803.898.8554.
Sincerely,
51
[Local Privacy Officer, Medical Records/HIS Director, etc. with contact info if not included in letterhead]
Attachment (Authorization)
MODEL NOTICE PROHIBITING RE-DISCLOSURE
[LETTERHEAD]
[DATE]
[NAME]
[FAX/ADDRESS]
The attached or enclosed information is been disclosed to you from records whose privacy is protected from
disclosure by federal and state law including, as applicable, 45 CFR Part 160 (HIPAA); 42 CFR Part 2,
(alcohol and drug Treatment) and Section 44-22-100, Code of Laws of South Carolina. The applicable law or
laws may prohibit you from making any further disclosure without the specific written authorization by the
individual to whom it pertains or their authorized representative, or as otherwise permitted or required by law. A
general authorization for release of information is not sufficient for this purpose unless it conforms to the
specific requirements of the applicable law or laws. Further disclosure not in accordance with applicable
federal and law may result in civil and/or criminal penalties.
Sincerely,
[Local Privacy Officer, Medical Records/HIS Director, etc. with contact info if not included in letterhead]
52
MODEL REPLY TO REQUEST TO INSPECT AND/OR COPY
[LETTERHEAD]
[DATE]
[NAME]
[ADDRESS]
Dear Sir/Madam:
In reply to your request to inspect and/or copy your SCDMH protected health information dated___________:
□
We have decided to grant your request.
□ Your appointment to inspect the requested information is ___________________________.
□ As the information is in multiple locations please contact me to arrange access
□ Copies, or if agreed to, the written summary of the information, will be available _________.
The charge for copies/written summary is _________, plus any applicable postage _____ .
□
We do not maintain the requested PHI, please direct your request to ____________________
___________________________________________________________________________
□
We have decided to deny your request because of the following:
□ The request is for Psychotherapy Notes
□ The request is for information needed for a DMH legal proceeding
□ The request is for research information
□ The request is for information given in confidence and is likely to reveal the source of information
□ A DMH licensed health care professional determined that access is reasonably likely to endanger
your or another person’s life or safety.
□
Other ____________________________________________________________________________
If we denied your request, you may send us a written request for a review. We will designate a licensed health
care professional who was not involved in the denial decision to review the denial. The designated person will
then notify you in writing within 15 days of your review request, the decision, and take other action necessary
to carry out the decision. You may also file a complaint with DMH and/or HHS as described in the SCDMH
Notice of Privacy Practices. If needed, contact me at the address or phone number noted on our letterhead.
Sincerely,
Privacy Officer
53
MODEL REPLY TO REQUEST FOR ACCOUNTING LOG
[LETTERHEAD]
[DATE]
[NAME]
[ADDRESS]
Dear Sir/Madam:
In response to your written request dated ___________, we have enclosed a copy of our disclosure accounting
log pertaining to our disclosure of your protected health information. In accord with applicable law, the log
does not include some information such as information used or shared for Treatment, Payment or Operations,
or information shared to you or by your written authorization, information disclosed: for national security or
intelligence; to correctional or other law enforcement facilities; or for notification purposes.
If this is other than your first request within a 12 month period, we have determined a reasonable charge for
copying and mailing of $ ________. Please send this amount to me at the address noted on our letterhead.
If you have any questions, please call me at the number on our letterhead.
Sincerely,
Privacy Officer
54
MODEL REPLY TO REQUEST TO AMEND
[LETTERHEAD]
[DATE]
[NAME]
[ADDRESS]
Dear Sir/Madam:
In reply to your request to amend your SCDMH protected health information dated__________, based upon
the attached review explaining the basis for our determination:
□
After review, we have decided to grant your request and make the amendment as noted. Please sign
below and indicate:
□ I agree with the amendment as written on the review attached.
□ I give my permission to notify necessary relevant persons of the amendment (Note that even without
permission, SCDMH may have the authority to make such notification.)
_______________________________________________________________
Consumer’s Signature
Date
□
After review , we have decided to deny your request because of the following:
□
□
□
□
The information was not created by SCMDH
The information is not part of a SCMDH Designated Record Set
The information is accurate and complete
Other______________________________________________________________
If we have denied your request, you have the right to send us a one-page written disagreement with the denial,
stating the basis for your disagreement. You may also request in writing that future disclosures of the disputed
information include your request for amendment and the denial. You may also file a complaint with DMH
and/or HHS as described in the SCDMH Notice of Privacy Practices. If needed, contact me at the address or
phone number noted on our letterhead.
Sincerely,
Privacy Officer
55
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Client Name:___________________________________________
Client Address: _________________________________________
_________________________________________
SSN:___________________________________
DOB:__________________________________
CID:___________________________________
I authorize the disclosure (release) of information pertaining to my health care or payment for health care (Information)
protected by HIPAA, and other applicable law, as follows:
Information authorized to be disclosed:
 All information
 Diagnoses
 Clinical History & Evaluation
 Admission and Discharge Dates
 Individualized Treatment Plan Progress Summaries
 Discharge Summary/Summary of Treatment
 Physician’s Medication Orders
 History and Physical
 Psychiatric History and Mental Status Examination
 Consultant Notes
 Billing and Payment Information
 Written summary
 Other:_________________________________________________________________________________________
I authorize my information to be released via:
Mail
Fax
Verbal
I understand that this Information may include information about diagnoses/treatment for alcohol or other drug abuse and
HIV/AIDS/ARC.
I authorize the release of this information for the time period from ___________________ to ______________________.
Purpose of disclosure:________________________________________________________________________________
I do not want the following information disclosed:_________________________________________________________
__________________________________________________________________________________________________
Name and address of person(s), facility, etc. authorized to disclose my Information:
 Berkeley Community Mental Health
† _______________________________
P. O. Box 1030
Moncks Corner, SC 29461
843-761-8282 Phone; 843-761-7308 Fax
________________________________
________________________________
________________________________
Name and address of person(s), facility, etc. to whom my Information may be disclosed:
† ________________________________
 Berkeley Community Mental Health
P. O. Box 1030
Moncks Corner, SC 29461
843-761-8282 Phone; 843-761-7308 Fax
________________________________
________________________________
________________________________
Authorization expiration date or expiration event:__________________________________________________________
(Authorization valid for one year from signing unless an earlier date, condition or event is specified)
I understand that I may revoke (cancel) this Authorization by writing to the facility authorized to disclose my Information
(above). Upon receipt, I understand that the facility will make no further disclosures of my Information pursuant to this
Authorization, except to the extent that such Information was already disclosed prior to my revocation, or if disclosure of my
Information is otherwise permitted or required by law. I also understand that Information disclosed by this Authorization may
be subject to re-disclosure by the recipient of my Information, unless otherwise restricted by applicable law. I have been given
a copy of this Authorization.
__________________________________________________________________________________________________
Signature
Printed Name
Date
If signed by a personal representative, describe that person’s authority to act for the individual:______________________
56
__________________________________________________________________________________________________
DISCLOSURES IN LEGAL PROCEEDINGS
Information regarding a DMH Consumer or a person for whom commitment has been sought is
protected by applicable federal and state law and may be used or disclosed only under the conditions
described in the DMH Privacy Practices Directive.
Depositions: If a DMH employee is subpoenaed to provide testimony and/or provide documents (i.e.,
"subpoena ducus tecum") in a civil deposition, send a reply “SCDMH NOTICE OF APPLICABLE
PRIVACY LAW” to the attorney issuing the subpoena, notifying the attorney that such information
cannot be provided without compliance with HIPAA and Section 44-22-100 of the Code of Laws of
South Carolina. Unless excused by the attorney, the employee must go to the place designated, but
should not provide information regarding the Consumer’s PHI unless a court order is provided or the
Consumer has signed an Authorization giving authority for such disclosure, or other exception as
described in the DMH Privacy Practices Directive.
Other subpoenas or requests for documents: If an employee is subpoenaed or receives a request
from an attorney or other person or entity, to provide documents (i.e., "subpoena ducus tecum"), send
a reply “SCDMH NOTICE OF APPLICABLE PRIVACY LAW” to the attorney issuing the subpoena,
notifying the attorney that such information cannot be provided without compliance with HIPAA and
Section 44-22-100 of the Code of Laws of South Carolina. Information regarding a Consumer should
not be disclosed unless a court order is provided, or the Consumer has signed an Authorization giving
authority for such disclosure, or other exception as described in the DMH Privacy Practices Directive.
Sending the reply “SCDMH NOTICE OF APPLICABLE PRIVACY LAW” notice will not excuse the
employee from appearing at the date, time and location designated in the subpoena if the subpoena
commands the employee's presence. However, the letter will legally preserve the objection to
producing the records, as well as place the attorney on notice of the applicable law and need for
Authorization or court order.
Court Testimony If an employee is subpoenaed to go to court for a court hearing or other legal
proceeding, to provide testimony and/or provide PHI, the applicable employee must go (and take the
record if so indicated). Upon taking the stand and being sworn, the employee will usually be asked
preliminary questions (name, place of employment, education, etc). When the preliminaries are
finished and the questioning regarding the PHI begins, the employee should not provide such
information, absent written Authorization, or prior court order, unless the judge takes notice of the
applicable law and decides that disclosure is necessary. To get this determination on the court's
record of the proceeding, the employee should advise the judge as follows:
Your Honor, paragraph two (2) of South Carolina Code Section 44-22-100 will not allow me to
disclose information about a patient or former of the Department of Mental Health or a person
for who commitment has been sought, until the court “directs that disclosure is necessary for
the conduct of the proceedings before it and that failure to make the disclosure is contrary to
the public interest.”
If the judge then directs that the question be answered and/or documents provided, an employee
should do so. If the employee feels that the testimony will do irreparable damage to treatment if
released in open court, the employee may ask to confer with the judge in private to explain his or her
concern. Such conferences in chambers and any ensuing actions by the court are matters within the
judge's sole discretion.
Copy of Record When an original record is taken to court, deposition or other proceeding, a copy of
some or all of the record that will likely be needed for evidence should also be taken. Only copies
should be surrendered for exhibits or other record to be retained by the court or other entity
conducting the proceedings.
57
UNIDENTIFIABLE OR DE-IDENTIFIED INFORMATION
Information may be disclosed, as determined by a person designated by DMH who has
appropriate knowledge of and experience with generally accepted statistical and scientific
principles and methods that the applicable Information is not individually identifiable. The
designated individual must apply such principles and methods necessary to determine that
the risk is very small that the Information could be used, alone or in combination with other
reasonably available Information, by any recipient to identify an individual who is a subject of
the Information; and the designated individual documents the methods and results of
analysis that justify the determination.
Unidentifiable or Deidentified Information cannot contain:
Names
All geographic subdivisions smaller than a state, including street address, city, county,
precinct, zip code, and their equivalent geocodes, except for three digits of a zip code if,
according to current publicly available data from the Bureau of the Census:
The geographic unit formed by combining all zip codes with the same three initial digits
contains more than 20,000 people;
The initial three digits of a zip code for all such geographic units containing 20,000 or fewer
people are changed to 000;
All elements of dates (except year) for dates directly related to an individual, including birth
date, admission date, discharge date, date of death; and all ages over 89 and all elements
of dates (including year) indicative of such age, except that such ages and elements may be
aggregated into a single category of age 90 or older;
Telephone numbers;
Fax numbers;
Electronic mail addresses;
Social security numbers;
Medical record numbers;
Health plan beneficiary numbers;
Account numbers;
Certificate/license numbers;
Vehicle identifiers and serial numbers, including license plate numbers;
Device identifiers and serial numbers;
Web Universal Resource Locators (URLs);
Internet Protocol (IP) numbers;
Biometric identifiers, including finger and voice prints;
Full face photographic images and any comparable images; and
Any other unique identifying number, characteristic, or code, unless no
individual could be identified in any manner and the number or code is not derived from or
related to Information about the individual. The designated person must attest, on behalf of
DMH, to having no actual knowledge that the Information could be used alone or in
combination to identify a subject of the Information.
58
SECTION 12
BERKELEY COMMUNITY MENTAL HEALTH CENTER
MEDICAL RECORDS SECURITY
In order to track records through the facility, it is necessary that all records be signed both in and out of the file room. Bar
code system will be the preferred process. In instances when the system is down, they will be signed in and out by hand.
Moncks Corner Office:
1.
Clinician’s scheduled appointments shall be pulled for them and be ready on the morning of the appointment day
to be picked up in the chart room. Each record will be signed out and signed in again when returned. Clinicians
should return records throughout the day and not wait until the end of the work day.
2.
Records should be signed out listing first and last name of client.
3.
If a previously closed chart is to be removed from the file room for any purpose by any staff member, it must be
signed out.
4.
Charts being returned to the chart room should be received by the medical records clerk for checking in and refiling.
5.
Charts being signed out for physicians should be signed out for the particular physician requesting the chart. At
that time, the chart may taken to the physician's wing and secured in the locked holding cabinet.
6.
Clinicians should not go into the Medical Records room. Access is limited to the door. A medical
records clerk should be available to help at all times.
FILING PROCEDURES:
A.
All are filed using the Alpha Random system.
B.
One cabinet is designated as the holding area for charts to re-filed into the general population.
Each clinician has a separate holding for records needed the next working day.
C.
Staff members will have access to records during regular working hours each work day.
D.
At the end of the work day the file cabinets and the file room will be locked.
E.
No charts are to be left in the clinician’s office. All charts are to be returned to the designated holding
areas.
Physicians Wing
A.
One cabinet is available to house all the charts needed by the physicians on a daily basis. Holding
sections are specifically marked for each physician. This cabinet is to be kept locked at all times.
B.
At the end of the work day, the file cabinet and reception room will be locked.
Filing Closed Charts
1.
They are filed using the Alpha Random system, the system used
for the open files.
2.
Closed charts are kept for three years before sending to be scanned. Records that have been scanned are
readily available for clinician use by requesting from the QA office
3.
Microfilm is kept in Columbia at the DMH and needs to be requested for copying.
59
Section 13
ALLERGY STICKERS
Allergy stickers are to be used on the exterior of charts.
1.
Case Managers are responsible for labeling records of their current caseloads.
2.
Assessment/Intake is responsible for applying them to new records.
3.
If a patient develops or reveals an allergy after his assessment, it is the Case Manager who applies the allergy
sticker.
4.
The Medical Records Clerk has the allergy stickers and is responsible for distribution and supply.
Allergies to medicines, bee stings, etc. should be listed on the labels. It is not necessary to list food allergies, etc.
The allergy sticker is to be placed on the center of the front of the chart. The top of the label is to be parallel to the metal
binder.
If a chart has multiple parts, the allergy sticker is necessary only on the part containing the current information. There is
no need to place a sticker on the older part(s). However, you should not remove allergy stickers from the older parts of
the chart if they are already present.
60
SECTION 14
BCMHC CLINICAL GUIDELINES FOR CARE
The following table is a set of guidelines for admission, discharge, continued stay, length of stay, services
offered in each program, admission GAF scores, Diagnosis, and risk assessment. Keep in mind that these are
only guidelines and do not replace clinical judgement. Always a consumer’s best interest and the best way to
meet that consumer’s need is of foremost consideration. The Center’s programs are listed from highest risk to
lower risk assessment. These guidelines should be considered when placing a consumer in any program. The
guidelines are not meant to exclude anyone from needed care.
In formulating this table, DMH regulations, CARF guidelines and other requirements were considered. This
document will reconsidered, and reviewed at least every year to keep it up to date. Please add this to your QA
manual under Section 16.
61
BERKELEY COMMUNITY MENTAL HEALTH CENTER
CLINICAL SERVICES GUIDELINES FOR CARE
Level of Care
(Most
restrictive to
least
restrictive)
Crisis
Intervention
(Adult and
children)
Crisis
Diversion
(Adult)
Intensive
Community
Services/ACT
(Like)
(adults and
Children)
HomeShare
(Adults)
Outpatient Therapy
(Children and
Adults)
Case Management
(limited therapy)
(Child and Adult)
Med Support
(Child and Adult)
Case Management
Risk
Assessment
: Danger to
Self or
Others
high
high
high to moderate
high to
moderate
High to moderate
Moderate to Low
Diagnosis
DSM IV dx
DSM IV dx
DSM IV
SPMI adults
Emotionally
Disturbed
Children
SPMI -DSM IV
dx
-Anx d/o
-Adj d/o
-Depression
-Personality d/o
-Dual dx (A&D)
-Schiz d/o
-Affective d/o
-Psychotic d/o
-severe Pers. d/o
-Dual dx (A&D or
MR)
DSM IV dx
requiring medication
Admission
Criteria
experiencin
g
-dec
function
-incr
distress
-danger to
self or
others
-dec function
-incr distress
-danger to
self or others
-in need of
services to
prevent or
divert
hospital
admisssion
-able to
contract for
safety
-need for intense
community based
service to
stabilize client in
their environment
-hx of
hospitalizations,
numerous tx
episodes
-significant family
dysfunction
-Inconsisitant
involvement with
tx
-Client has been
in a long term
placement at a
hospital.
-will be willing to
share a home
with a “Foster”
family that has
been trained by
DMH to care for
a client with
SPMI
-dec function and
Inc distress in
response to
environmental
factors
-tx focused on cl
problem that
responds to
behavioral or
insight therapies
-no psychosis
-likely to require
referral/linking/adv
ocacy to other
comm. Providers
to support recovery
-potential for
relapse if not in
supportive
treatment
environment
-requires
significant
interventions and
support to function
-meets definition of
SMI or SPMI
adults
-sx are managed or
controlled by meds
-client has met goals to
his/her satisfaction and
only desires meds
Continued
Stay Criteria
NA
Physician
assessment
-cl continues to
be at risk for
decompensation
without
community
supports
-client requires
home situation
to continue to
function at
current level
and for support
in his
community
-danger of
relapse to
hospital
-danger of relapse
if therapy
withdrawn
-client dev new
goals
-would relapse if
supportive tx
withdrawn
-has not met goals
of tx
-continues need for
meds and monitoring of
same
Discharge
Criteria
-contract for
safety can
be made
-placed in
least
restrictive
envir for tx
-emergent
needs have
decreased
-can contract
for safety
-Hospitalized
-client more
stable and able to
manage
environment
-’safety net’
developed for
client (support
system)
-Client is able to
live independently or secures
other living
arrangement
-meets goals as
described by client
-distress and
function have
returned to an
acceptable levels
-meets goals as
described by client
-distress and
function are at
acceptable levels
for client and sig
others
Client has stopped
meds and is
functioning at desired
levels of function by his
definition
low
62
Level of Care
(Most
restrictive to
least
restrictive)
Crisis
Intervention
(Adult and
children)
Crisis
Diversion
(Adult)
Intensive
Community
Services/ACT
(Like)
(adults and
Children)
HomeShare
(Adults)
Outpatient Therapy
(Children and
Adults)
Case Management
(limited therapy)
(Child and Adult)
Med Support
(Child and Adult)
Case Management
-able to transition
back to outpt or
school based
services
Types of
services
expected to
be delivered
-Cr mgmt
-Assess
-PMA
-Case
mgmt
-Nursing
Services
-Cr Mgmt
-PMA
-Assess
-Case Mgmt
-Nursing
services
-Ind, fam tx
-WRAPS
-assess
-TCM
-PMA
-Crisis Interv
-Fam tx
-Ind tx-Group
-(community
based service)
-PMA
-Any service
appr. To client
needs
-Ind/Group/
Fam tx
-Assess
-PMA, TPFS
-limited CM
-Case mgmt
-supportive,
palliative, Ind,
Group, Fam tx
-PMA, SPD
-Assess, -PRS
-Nursing Serv
-Med Mon
-Med Admin
-CMG
Clinics
Estimated
Length of
Stay
1-2 visits
1-2 days
3-6 months
(according to
client needs)
1 year or more
6-9 months
1 year or more
1 yr or more
Speciality
Programs
Hospital
Diversion
HER respite
program
ICS
(children/families)
-Parenting Groups
-Anger
Management
ACT (like)
-DBT ind/group
Adults
-Co-occurring
groups
Med compliance
groups
-Skill groups
63
SECTION 15
ASSESSMENT FORMS
Each consumer receives a comprehensive assessment as part of the admission process. The following forms
give consideration to the kinds of information needed as part of this assessment. Here are some general
considerations when completing the forms. Do not leave blank spaces. If the consumer does not have the
information or the answer is none, mark the space as such. The initial clinical assessment (ICA) needs to be
completed within three non-emergency visits of the admission date.
Follow the prompts for each area to be addressed. You have three non-emergency visits to complete the
assessment form. If the form is not completed by the same person, you will need to initial and date the added
information. Sources of information include the consumer, family, other providers, or any person willing to
provide information, with consent from the client, of course.
The Medical Assessment is most often done by a nurse and is a part of the Initial Clinical Assessment. This
should be done within 3 non emergency visits from the time of admission, along with the ICA
At the time of a significant change in status for the client, the update form may be used. This form mirrors the
initial clinical assessment form and only needs to be updated with new information and current mental status
information. This applies to the provisional treatment plan as well. List any changes or new information that
may be pertinent to the treatment plan.
Discharge planning is very important from the beginning of treatment. The consumer may be limited to
projecting what things may look like for him/her, but it is important to begin the process of thinking toward
completion of treatment. What behavioral signs will be present? How will current behavior/thinking be
different?
If a client is readmitted to the Center within one year of the completion of the ICA, the update form may be
used at the time of readmission. You will be updating the information received at the previous admission. If the
form used for the ICA at the time of the previous admission is not the current form being used, complete the
initial assessment form currently being used.
The Hospital Discharge Assessment Form is used upon the first visit following discharge from a psychiatric
hospitalization. This helps to capture some of the information needed to assess trauma experienced related to
the client’s admission and treatment in an inpatient setting.
64
ICA Form Instructions (July 28, 2006 Form # C-183)
ADDRESS ALL PROMPTS!
ICA Page 1
Top of Form:
1. Center Name: pull down menu, click your Center
2. Date: type in date ICA started
3. Source of Data: click all that are used to complete the assessment
4. Referred by: click appropriate box. If Court order also type in the Type of court order
(DJJ, Outpt. MH), other could be parents, primary care physician, hospital ER, DSS, A&D,
etc.
1.
Section A: Identifying Data
5. Name: Type Last, First, Middle Initial (as on face sheet) and CID #, (Client ID number) (If
an entire page is not completed at one session, you will date any new entries and they will
correspond to the CSN for that date. Be aware that bill time is justified by information on
the ICA and any major exceptions need to be explained on the CSN. I.e.: 1 hour to
complete SNAP.
6. Identifying Data: Age: type in; DOB: month = drop down box, type in day and year;
gender, race, marital status = drop down boxes; other identifying information = type in but
is limited space (appearance, identifying characteristics, physical characteristics – real or
apparent height and weight (average, stocky, healthy, petite), any physical deformities
(hearing impaired, injured and bandaged right hand). Basic Grooming and Hygiene,
dress and whether it was appropriate attire for the weather, for a doctor's interview,
accessories like glasses or a cane .Gait and Motor Coordination (awkward, staggering,
shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect),
work speed, any noteworthy mannerisms or gestures
2.
3. Section B: Perceptions and History of Presenting Problem(s)
4.
□ Each source of information is to be addressed and include the name and
relationship of the person who gave the information. If in foster care the guardian will be
DSS. The foster family’s information is listed under Collateral Sources. Collateral Sources
could also be information received from the referring person.
5.
□ Ask each source of information the same question. If family is not available
(in person or phone) or consent to talk with them is not given you need to indicate this in the
appropriate block(s).
6.
□ Address all 4 blocks and each question within the blocks. Remember to
review the Referral Form and address issues identified on it.
7.
8.
Block 1: you are inquiring about the reason for coming in for treatment.
Looking for issues/problems (Px), psychiatric, emotional, behavioral symptoms (Sx), history
(Hx) of problems e.g. When did they start? How long? Intensity? and any stressors? Use
quotation marks to indicate his/her exact responses. This is the start of determining the
treatment plan. Needs to be more than “my momma said I had to come”. Next question
would be “what is/was going on that momma thinks you need to come to the center?”
9.
10.
Block 2: Ask each (client, family and collateral) what is his/her thinks
caused/triggered the problem.
11.
12.
Block 3: Ask each what area(s) of the client’s life and who if anyone else is
affected by the client’s problem. How/Does the problem affect the client’s thoughts of
him/herself, does this impact how the others think of the client? Possible areas: family
relationships, work, marriage, friendships, school.
65
13.
14.
Block 4: Ask each what they think will help make it better. This gives an
indication of what they want from the Center: medications, coping or relationship skills
development, or anger management, etc. Ask if anything helped in the past, types of
treatment, referrals, etc.
ICA Form Page 2
Enter Name and CID # at top of pages 2 – 8 (by copying and pasting now - saves time)
15.
Section C: Urgent Needs/Risk Assessment
16. □
Risks: Ask about each area (suicidal, homicidal, self mutilation and other risk
taking
behaviors), click appropriate blocks.
17. □
Comments: address any checked blocks (other than denies) in each risk
question.
History of
suicidal and/or homicidal/assaultive acts would go here. Note if
affected by substance use.
18. □
Steps taken to address urgent needs: This is what is done at time of intake if
urgent needs
are identified. Example: Referred to physician for immediate evaluation,
assessment stopped
to deal with immediate safety issues, admitted to an inpatient
facility, etc.
19.
20.
Section D: History of Mental Health Treatment
21.
Client:
□ Click None if they deny having any prior MH Tx.
□ List any and all treatments the client has received in order of occurrence.
□ None if denies or List and describe any family history of mental health issues or
treatment and relationship
Example: June 1982- Nov. 2002 - ABC MH Center, NY; Dx.-depression; Tx. type-monthly
Dr. appts, for medications; stopped Tx. due to moving out of state.
August 1999 - Inpt. Tx. @ Bellevue Hospital, for 3 weeks. Suicide attempt, overdose of
antidepressants, and depression, DBT and Zoloft; couldn’t afford outpatient follow-up.
Family:
□ Check none if they deny any family history
□ List the relationship and type of mental health problems, treatment, and Dx. if known.
ICA Form Page 3
Section E: Trauma History
□ Each Center may or may not be participating in the Trauma Initiative. Reference to the
Trauma Assessment Form is done by checking the “See Trauma Assessment Form
Check box”.
□ Check appropriate boxes if none is check for history and type of trauma then skip the
“Was
client” and “Describe issues identified” sections. If trauma is identified then
describe the issues/difficulties they are experiencing.
Section F: Substance Use
Check Boxes
Address/ask about each substance, if used indicate the age started, frequency and quantity,
method and last use. If admits to using some but not others fill in the info to the applicable
ones and leave the others blank. Example: Cannabis: 16yo, 1-2 joints/per weekend,
smoked, 3 days ago. : If denies any use check the “Denies” block and go to Family Hx of
substance abuse. (Item 5 under “Substance Use Treatment”)
66
Substance Use Treatment: enter all treatment episodes starting with date, include location,
dates, type of treatment and how and why ended. Use N/A or None Reported if applicable
Substance Use Experiences: Ask about each 1-5, if answer is yes, describe in the line
beside the question.
ICA Form Page 4
Section G: Medical History and Current Status
Some Centers use The Medical Assessment Form, which is a nursing assessment form. If
the Medical Assessment Form is completed this section does not have to be done. Refer to
medical assessment form by checking the block. The MAF will need to be completed within 3
scheduled visits. If any blocks are checked for current or history they must be addressed in
the comments section. Example: Heart Attack 1994, MVA -fractured left femur -1968, shot,
or stabbed. Head Injury from fall in 1968, etc. ! ! ! Remember to ask for authorization to
obtain medical information from hospitals and PCPs if applicable ! ! !
Check the “C block” beside “No physical sx/problems” if they currently do not have any
problems and leave the other “C” blocks blank but you may check “H” Boxes since they could
still have a history of certain ailments. The Surgery and STD specify blocks, if applicable;
information is to be entered in the comment section.
Skip to Significant Family History. Either fill in the family history if any (indicated the
relationship) or type/write in denies are none identified or does not know
Medication: List all medications prescribed and over the counter. Remember to ask about
herbs and vitamins
List Medication Allergies and Adverse Reactions to medications
Primary Care Physician, phone number and date last seen. Who do they see for medical
problems? When entering the date last seen you must enter it as mm/dd/yy, if not it changes
when tabbed to the next item.
If he/she does not have a primary care physician, indicate if community resources
were given to the client by checking yes or no. If yes, list the type of resources given.
Example: “List of local physicians and health care centers given:
ICA Form Page 5
Section H: Social Economic and Cultural
Ask and address all questions and prompts. Do Not Leave Blanks - use denies or unknown,
none or N/A as appropriate.
1. What state/town born and raised?
2. Family of origin - natural parents-married, divorced, adoption, foster care, siblings, and
extended family; relationship current and past with family of origin.
3. Current family/significant relationships, children and relationship with them- 2 adult
children son and daughter who live independently but visits every Sunday. 3 grandchildren,
baby sits 2 yr. g.son.
4. Past relationships- got along with others, always a loner etc
5. Significant losses/separations through war, divorce, death, limbs, eye sight etc.
6. Current housing arrangements…consider if they need assistance or referral in this area.
7. Ask about issues with sex/sexuality – list or denies any problems
8. Activities they enjoy with others- talking on phone, doesn’t like to be around others
9. Current religious involvement. Attends church 3x week, Sunday school teacher,
practicing Buddhist, or Atheist.
10. Educational background if applicable, why he/she quit school, performance in school,
any area of special training/expertise.
67
11. Current & Past employment length of employment, if unemployed - why, work history
and reasons for quitting/being released from prior employment. Military Service? Type of
work he/she would like to do.
12. List any past & current legal issues pending court orders, charges, marital legal issues,
custody issues. Is treatment court-ordered? –be sure to indicate on page 1
ICA Form Page 6
Section I: Strengths, Needs, Abilities, and Preferences
(SNAP is client's words (some need help to identify) FYI these prompts are more specific
than the ones on the POC which are more global.
Strengths: support (family, spouse, social, spiritual), hobbies, neighbors, caregiver,
employer, other agency, etc) and attitudes that have helped in the past.
Desire to succeed, cooperative, motivated, receives guaranteed income, etc.
Needs: emotional, physical, social, environmental. Hearing impaired, transportation,
vocational training and/or placement, to complete education, recreational or social outlets,
friends, on-going medical care for medical problems, housing, legal assistance, A&D
treatment, etc.
Abilities: ability to follow up with treatment, understand instructions, participate in treatment ,
can cook/clean & other ADLs, balance checkbook, drivers license, can read & write, takes
medication per instruction, abstains from ETOH/drug use, vocational & avocational skills,
etc.
Preferences: outpatient vs. inpatient treatment, appointments certain days or time of day,
frequency, male vs. female casemanager, medications vs. no medications, denominational,
cultural, etc.
Section J: View of Treatment and Discharge
Client’s expectations: What client wants to happen; and what they expect from treatment;
these are the foundation for the goals on the ITP.
Family’s expectations: Same as above but from the Caregiver’s perspective if applicable. Do
they want to be involved in treatment, need referral to support group, NAMI, education
regarding mental illness? Name the family member and relationship.
Client’s commitment and motivation to treatment: The motivation will give insight into the
commitment to follow the treatment plan and medication compliance and indicative of the
outcomes. Use the motivation and depth of commitment when developing the POC. Is the
person willing to come to appointments as scheduled and participate in treatment process via
working in sessions and doing outside assignments/homework (as applicable).
Family’s commitment and motivation to treatment: How can they best help the client,
indicates willingness to support the client and themselves to learn skills and /or behaviors to
address the issues.
Client’s and Family’s Discharge Criteria: What will be different or what must happen for
him/her to no longer need center services? Very important, this needs to be jointly identified
whenever possible. Sometimes an individual may need continued support / services from the
Center but to varying degrees. (“Discharge is not appropriate but treatment (intensity and
68
frequency) will be adjusted to the identified needs.”) Be specific about what needs to be
different or how they will know and measure they are ready for discharge: “I can fall asleep
and sleep all night 5 nights a week”. “My child will go from failing all subjects to making C’s.”
“No more legal problems.” “I get a job.” “I stop crying for no reason.” “8 weeks without in
school suspension or discipline notes”. These can be broken down into smaller objectives for
the ITP. “Ask the person, what will your life/circumstances/sx look like when you are ready
for transition to less frequent/intense services and/or discharge?”
ICA Form Page 6 (con’t)
Section K: Mental Status Exam
Any blocks checked that are not normal range or response can be elaborated on in the
comment section.
Appearance and Hygiene: Check appropriate descriptor and write in when indicated (dress,
gait, posture, eye contact, nutritional status, etc.)
Motor Activity (check appropriate descriptor)
Attitude During The Interview (check appropriate descriptor)
Affect (check appropriate descriptor) how they felt a given moment (comments can include:
“consistent with the content of the conversation and facial expressions”, “cried while
discussing recent happy event and unable to explain why”.
Mood (check appropriate descriptor) how they feel most days. Note level of emotion
dysregulation and behaviors that indicated it, ways the client has handled it.
Speech (check appropriate descriptor)
ICA Form Page 7
Thought Process: (check appropriate descriptor)
Difficult to understand line of reasoning, confabulations, illogical thinking, grandiosity, magical
thinking, perseveration, delusions, reports of experiences of depersonalization). Abstraction
Skills
These are based on proverbs, sayings, similarities ("How are a ______ and a ______ alike?
Different?"), and giving both definitions for word ("What are two different meanings for the
words 'right,' 'bit,' and 'left'?") Examples of proverbs and sayings are: ("What do people mean
when they say... A rolling stone gathers no moss, All that glitters is not gold, Don't count your
chicken before they hatch, Don't put all your eggs in one basket, Strike while the iron is hot,
Rome wasn't built in a day, When the cat's away the mice will play, A stitch in time saves
nine.")
What would I mean if I said I am feeling blue? seeing red? I have a chip on my shoulder? or
hot under the collar?
Thought Content: (check appropriate descriptor) If suicidal/homicidal – see the risk
assessment pg. 2. Describe, including plans and intent. Are there things that worry you a lot?
Have you ever felt an intense fear or worry that something bad would happen to you? Are
there specific things that frighten you? (anxiety)
69
Do you ever feel the need to do something over and over until it's perfect? Are there certain
things you sometimes feel compelled to do over and over? Are there ever thoughts that you
just can't get out of your head? (Compulsions and Obsessions)
Hallucinations: check any/all that apply and describe.
Delusions: check any that apply and describe if other than no evidence
Orientation/Level of Consciousness: Check all that apply
Judgment: (check appropriate descriptor)
ICA Form Page 7 (con’t)
Insight/Adjustment to Problems/Illness, Disabilities, Disorders: check appropriate
descriptor
Memory: Check the appropriate box. Document (in comments) the test to assess memory.
Intact or document incorrect responses which indicate difficulties with memory. Recent Past:
after ten minutes ask Client to repeat the name of the four objects, ask what they did
yesterday (meals, activities, etc.) Remote Past: ask birthday, dates of school attendance,
marriage, birthdates of children, military discharge, other important chronological facts.
Immediate: (Registration and Recall) name four objects and ask Client to repeat them
Concentration and Calculations: check the appropriate box. Document the test(s) (in
comments) and result/answer. Ability to pay attention: does Client ask you to repeat
questions?
Based on Digit Span and attention to your questions, serial 7's or 3's in which they count
backwards from 100 to 50 by 7s or 3s, naming the days of the week or months of the year in
reverse order, spelling the word "world", their own last name, or the ABC's backwards)
Fund of knowledge; check the appropriate box. Document the test(s) and results/answers
(in comments). Problem-solving ability, estimate of general level of intellectual functioning,
based on answers to questions like "name last four presidents," "who is the governor of the
state," "what is the capitol of the state," "what direction does the sun set," etc...) Results of
testing, if any and who did the testing: IE: IQ testing score and who did it
Other Pertinent Information: complete as needed or N/A. Impulsivity (low medium, high,
affected by substance use). Do you ever find yourself suddenly doing something before you
have really had a chance to think about it? Do you ever do things you had decided not to do,
and don't know why? Does money "burn a hole in your pocket"? Facial and Emotional
Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert,
day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such)
Sleep Patterns: How are you sleeping? Do you have trouble falling asleep, staying asleep,
waking up? Note: Some antidepressants work best with clients who have trouble falling
asleep, while others work best with those who can't stay asleep or wake up.
Appetite/Eating Patterns: How is your appetite? Do you think your eating habits are
unusual? What is your weight now? What is the most and least you've weighed? Are you
concerned about your weight? (Eating Disorders)
70
Energy Levels: How is your energy level though the day; do you have enough energy to get
things done? Have you ever had so much energy you couldn't sit still? That you didn't need
to sleep for days at a time? (Mania)
Libido: How is your libido, would you describe it as adequate, increased, or decreased?
ICA Form Page 8
Section L: DSM-IV Diagnosis
Axis I: Specify numerical code and name of disorder as appears in DSM-IV
*If applicable, note severity/psychotic/remission/chronicity specifiers
*Insure that diagnosis given meets DSM-IV diagnostic criteria for that diagnosis and
document all supporting symptoms that the client presents/reports.
Axis II: DSM-IV numerical code and name of disorder (or absence of)
Must include code; do not use >rule-out= if no diagnosis note V71.09 or if deferred
Diagnosis use 799.9 You can also note either of these two codes
if there are symptoms of
an axis II diagnosis but not sufficient to meet diagnostic
criteria. In this case, also write in
the observed traits. Example: 799.9 Borderline
Personality Traits.
Axis III: State general medical conditions (e.g. diabetes)
Axis IV: State psychosocial and environmental problems (e.g. divorce, loss of job)
Axis V: GAF score at time of assessment. GAF score to be submitted to clerical to be
entered
into CIS. .
Section M: Interpretive Summary
The blocks in the heading are to be checked when that information is included in the body of
the summary. It is a way to insure that it is included. These are areas that have been
identified as frequently missed.
Interpretive Summary/Clinician’s Expectations:
This is a narrative summary and interpretation of all pertinent assessment data such as:
demographic factors, medical issues, past treatment history, reason for seeking services,
mental status, motivation, support, positive and negative factors, levels of functioning, and
co-occurring disorders.
This summary is the beginning of treatment, justifies the treatment/services rendered, and it
is the foundation of the POC. Issues defined here are incorporated into the POC. Include
the MHP’s recommendations for treatment and possible referrals. Include all factors that may
impact the outcomes, positive or negative.
Frequently, when a Client first enters our services they “just want to feel better” or “not go to
the hospital anymore” or “behave and mind their parents and or teachers” they need us to
guide them into setting obtainable goals and objectives. This summary will be the foundation
to jointly plan their treatment and is the basis for the diagnosis. A miscellaneous sheet may
be used for continuations.
If this form is used as part of the documentation for billing the CSN should be
referenced. Example: At the bottom of section M include: “See CSN # ________
dated________” the CSN will also reference this form.
71
Assisting Staff’s Signature/Title and Date: If another clinician assists in gathering some of
the information they are to sign in this block.
Clinician’s Signature/Title and Date: The MHP who minimally completes sections: B, C, E,
I, J, K, L, and M but reviews the data to complete section M.
H:\TRAINING QA\ICA 2006 ADULT INSTRUCTIONS DRAFT 3.DOC
Carolyn Cohen 9/6/06
72
BERKELEY COMMUNITY
MENTAL HEALTH CENTER
Initial Clinical Assessment
Date:
Source of Data:
Referred By:
Court Order: (Type)
Self
Client
School:
Old records
Family:
Other:
Other:
Section A: Identifying Data
(First)
Name:(Last)
Age:
DOB:
Gender:
(MI)
Race:
CID#
Marital Status:
Other Identifying Information:
Section B: Perceptions and History of Presenting Problem(s)
Documentation should address the source of information and the following:
(1) What brought client here today (px, sx, hx, duration and stressors)?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
(2) What are the possible causes? Why does the client think she/he is having these problems/symptoms?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
(3) Who and what area of client’s life are affected by this? How does this make client/family member feel about him/herself?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
(4) How does client/family think this can be solved? What will help?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
SCDMH FORM
MAY 2005 (REV JUL. 2006) C-183 (FM Jul 28,2006)
PAGE 1 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
Name:
CID#:
Section C: Urgent Needs/Risk Assessment
Suicidal Risk:
Denies
Ideas
Plans
Means
Intent
Hx of attempts
Hx in family
Homicidal Risk:
Denies
Ideas
Plans
Means
Intent
Hx of attempts
Hx in family
Self Mutilation:
Denies
Ideas
Plans
Means
Intent
Hx of attempts
Hx in family
Other Risk Taking Behaviors:
Past or current (Specify in comments section.):
Driving fast/DUI
Unprotected sex
Gang affiliations
Denies
Fire setting
Hx of violence
Other
Comments:
Steps taken to address urgent needs:
Reviewed emergency procedures with client/family.
Identified emergency contacts: 211 Family
Friend
Other:
Developed Personal Safety Plan:
Identify triggers and warning signs that may lead to escalating behaviors/crisis:
Identify coping skills the client has that can be utilized to prevent a crisis:
Preferred interventions for de-escalating behaviors/crisis:
Identify any type of advance directive the client may have:
Section D: History of Mental Health Treatment
A chronological history of all inpatient and outpatient treatment to include location, date of treatment, diagnosis, type of treatment,
and how/why ended.
None
Family Mental Health History:
None
Describe history and specify relative:
SCDMH FORM
MAY 2005 (REV JUL. 2006) C-183 (FM Jul 28,2006)
PAGE 2 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
Name:
CID#:
Section E: Trauma History
See Trauma Assessment Form)
None apparent
Signs/sx present, but denies
Acknowledges
Referred for assessment
History of Trauma/Violence/Abuse/Neglect:
Type of Trauma/Violence/Abuse/Neglect:
None
Sexual
Physical
Natural Disaster
Was client:
Victim
Witness
(
Emotional
Self/someone else was going to die/be killed
Accident (specify):
Perpetrator
Describe issues identified: (nightmares, flashbacks, startle reflex, avoidance):
Section F: Substance Use
Denies (go to Family Hx of Substance Abuse)
Substance
Age Started
Frequency/Quantity
Method
Last Use
Alcohol
Cannabis
Sedatives (Benzodiazepines, Barbiturates)
Stimulants (Crack, Cocaine, Methamphetamine, Speed)
Hallucinogens (LSD, Mushrooms, Mescaline)
Opiates (Heroin, Codeine, Morphine)
Inhalants
Steroids
Caffeine
Nicotine
Other
Substance Use Treatment (A chronological history of all inpatient and outpatient treatment to include location, dates of treatment,
type of treatment, and how/why ended.):
Substance Use Experiences:
1) Experienced blackouts?
Yes
No If yes, describe:
2) Withdrawal symptoms (seizures, DT’s, etc)?
3) Legal involvements related to substance use?
Yes
Yes
No If yes, describe:
No If yes, describe:
4) Is your alcohol/drug use something that needs to be addressed in treatment?
5) Family history of substance abuse?
SCDMH FORM
MAY 2005 (REV JUL. 2006) C-183 (FM Jul 28,2006)
Yes
Yes
No If yes, describe:
No If yes, describe:
PAGE 3 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
Name:
CID#:
Section G: Medical History and Current Status
C
C = Current problem
C
H
H
(
See Medical Assessment Form)
H = Client has a history
C
H
No physical sx/problems
Kidney/bladder problems
STDs (specify)
Thyroid
Stomach/intestinal problems
Other (specify)
Seizures
Serious body/head injury
Severe headaches/migraines
Heart problems/Hypertension
TB
Epilepsy
Date of last menstrual period :
Cancer (specify):
Liver/Hepatitis
Pregnant?
Lung problems
Immune disorder
# of pregnancies
Diabetes (specify if juvenile or adult
Surgeries (specify)
# of living Children
onset)
Allergies:
Females:
Yes
No
Comments: (Describe status of any current physical conditions. Describe any significant history.)
Significant Family History:
Medication: (List all current medications: prescribed and OTC, including herbs, vitamins, etc.):
Name of medication
Dosage
Frequency
Why prescribed?
Medication Allergies:
Adverse Reactions to Medication:
Primary Care Physician:
If none, community resources provided?
SCDMH FORM
MAY 2005 (REV JUL. 2006) C-183
Phone #: (
Yes
)
-
Date Last Seen:
No
PAGE 4 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
How well does it work?
Name:
CID#:
Section H: Social, Economic and Cultural
1). Where were you born and raised?
2). Describe your family of origin (who raised you, how many sibling(s), quality of relationships then and now):
3). Describe current family/significant relationships (significant other? children? quality of relationships?):
4). Describe past significant relationships (marriages, divorces, separations, etc.):
5). Describe any significant losses/separations of any family members/significant others (including loss of pets, physical functions,
limbs, property/possessions, etc.):
6). Describe current housing situation (house, mobile home, boarding homes, shelter, homeless, etc.): Any needs?
7). Any problems/issues/changes with sex/sexuality?
Yes
No
(If yes, describe):
8). Describe current social involvement (activities that you enjoy with others):
9). Describe current spiritual/religious involvement:
10). Describe educational background (how far in school, tech school, college, special ed., special programs, highest level completed):
11). Describe current and past employment (how long at each job, if on disability, include any military service/type of discharge, etc.):
If you could work now, what would you be interested in doing?
12). History of legal involvements (DJJ, charges, jail/prison time, #arrests and #convictions, as well as any current legal problems):
SCDMH FORM
MAY 2005 (REV JUL. 2006) C-183 (FM Jul 28,2006)
PAGE 5 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
None
Name:
CID#:
Section I: Strengths, Needs, Abilities, and Preferences
Strengths: (family, social, spiritual support, hobbies, and attitudes
that have helped overcome past crises)
Needs: (Client’s expression of current needs emotional, physical,
social, environmental)
Are you currently receiving services from other providers/agencies?
Yes
No
Specify:
Abilities: (Client’s ability to follow up with treatment, understand
instructions, participate in treatment)
Preferences: (appt., day/times, therapist, treatment modality, etc.)
Section J: View of Treatment and Discharge
Documentation should include the source and the following:
¾ What are your expectations?
Client:
Family (specify):
¾ What is your commitment and motivation to treatment?
Client:
Family (specify):
¾ How will you know when you will be ready for discharge?
Client:
Family (specify):
Section K: Mental Status Exam
List more than one descriptor if applicable. Elaborate on any problem areas in the space provided.
Appearance & Hygiene
Meticulous
Comments:
Motor Activity
Neat
Appropriate to situation
Clean
Disheveled
Over-active
Bizarre
Tremor/tics
Body Odor
Poor coordination
Repetitive
Lethargic
Comments:
Attitude During Interview
Affect
Cooperative
Comments:
Oppositional
Appropriate to situation
Hostile
Blunted
Flat
Dramatic
Guarded
Tearful
Irritable
Incongruent
Withdrawn
Expansive
Labile
Comments:
Mood
Happy
Euthymic
Anxious
Depressed
Angry
Hopeless
Suspicious
Passive
Comments:
Speech
SCDMH FORM
MAY 2005 (REV JUL. 2006) C-183
Normal rate and tone
Comments:
(FM Jul 28,2006)
Slow
Fast
Soft
Loud
Pressured
PAGE 6 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
Slurred
Stuttering
Alogia
Name:
CID#:
Thought Process
Normal, appropriate, coherent, relevant
Loose associations
Circumstantial
Tangential
Indecisive
Disorganized
Flight of ideas
Concrete
Blocking
Racing
Comments:
Thought Content
Normal
Phobias
Obsessions
Ideas of hopelessness
Ideas of worthlessness
Paranoia
Persecutory
Suicidal
Homicidal (Note: If suicidal or homicidal, see risk assessment)
Comments:
Hallucinations
No evidence
Auditory
Command
Visual
Olfactory
Tactile
Denies
Comments:
Delusions
No evidence
Persecutory
Grandeur
Reference
Influence
Somatic
Denies
Comments:
Orientation/Level of
Consciousness
Alert: Oriented to
Person
Place
Time
Situation
Clouded
Confused
Comments:
Judgement
Able to make sound decisions
Usually able to make sound decisions
Poor decision making, adversely affects self
Poor decision-making, adversely affects others
Comments:
Insight/Adjustment to
Problems/Illness,
Disabilities, Disorders
Denies problems/illness
Blames others
Acknowledges but fails to understand
Minimizes
Acknowledges & understands
Comments:
Memory
(use example )
Intact
Poor remote
Poor recent
Poor immediate
Comments:
Concentration &
Calculations
(use example)
Able to concentrate
Able to do simple math
Easily distracted
Daydreams
Comments:
Fund of Knowledge
(use example)
Above average
Average
Below average
Comments:
Other Pertinent Information:
Sleep Patterns:
Appetite/Eating Patterns:
Energy Levels:
Libido
Adequate
Hypersomnia
Adequate
Purges
Adequate
Adequate
Early awakening
Insomnia
Increased
Binges
Increased
Increased
Short intervals
Sleepwalking
Decreased
Doesn’t eat
Decreased
Decreased
Nightmares
Decreased need for sleep
Weight changes:
Lbs.
Other
SCDMH FORM
MAY 2005 (REV JUL. 2006) C-183 (FM Jul 28,2006)
PAGE 7 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
Fatigue
Name:
CID#:
Section L: DSM-IV Diagnosis
(Must include both code and description)
Axis I:
Criteria For Dx:
Axis II:
Axis III:
Axis IV:
Axis V:
Section M: Interpretive Summary
This is a narrative of the data gleaned during the assessment. It should include:
disorders
Justification for treatment
Priorities for treatment, include co-occurring
Recommendation(s) for treatment and referrals (including services and their frequencies)
Clinical judgement re: both positive and negative factors likely to affect the client’s course of treatment and clinical outcomes.
And it could also include:
diagnosis
Current levels of cognitive, emotional, and behavioral functioning
Issues present
Adjustments to disorder/disabilities.
Assisting Staff’s Signature / Title (if applicable):
Date:
Clinician’s Signature / Title:
Date:
SCDMH FORM
MAY 2005 (REV. JUL. 2006)
C-183
(FM Jul 28,2006)
PAGE 8 OF 8 (INITIAL CLINICAL ASSESSMENT SCDMH)
Basis for
Name:
CID:
General Symptoms:
Does the client experience…..
Affective:
Y N
Depressed mood
Length of time:__________
Decline in normal interests
Poor concentration
Indecisiveness
Excessive or inappropriate
guilt
Recurrent thoughts of death
Somatic
Persistently elevated or
irritable/angry mood
Grandiosity/↑ self esteem
More talkative or pressure
to keep talking
Easily Distracted
Increased goal directed
activity
Excessive involvement in
pleasurable activities
with potential for painful
consequences
Excessive worrying
Obsessive thinking
Compulsive behaviors: ____
________________________
________________________
Anxiety/Panic:
Y N
Palpitations,
pounding/racing
heart
Sweating
Trembling or shaking
Shortness of breath or
smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy/unsteady,
lightheaded or faint
Fearful they are dying
Derealization/depersonalization
Fear of losing control or
going
Crazy
Numbness or tingling
sensation
Chills or hot flushes
Worries about having these
symptoms again?
Worries about the
implications/consequences
of these symptoms?
Changes in behavior due to
symptoms?
Avoid/worries about going
places where escape might be
difficult or embarrassing?
Persistent fear of social
situations/embarrassment
Psychosis:
Y N
Delusions
Auditory hallucinations
Visual hallucinations
Olfactory hallucinations
Tactile hallucinations
Disorganized speech
Grossly disorganized or
catatonic behavior
Flat or inappropriate affect
Alogia (poverty of speech)
Avolition (inability to
initiate &
persist in goal-directed
activities
Anhedonia
Paranoia
Comments and Other General Information as needed:
Clinician’s Signature/Title:
Date:
81
CAF ICA Form Instructions (Aug. 9, 2006 Form # C-184)
ADDRESS ALL PROMPTS!
ICA Page 1
Top of Form:
6. Center Name: pull down menu, click your Center
7. Date: type in date ICA started
8. Source of Data: click all that are used to complete the assessment
9. Referred by: click appropriate box. If Court order also type in the Type of court order (DJJ, Outpt. MH),
other could be parents, primary care physician, hospital ER, DSS, A&D, etc.
22.
Section A: Identifying Data
10. Name: Type Last, First, Middle Initial (as on face sheet) and CID #, (Client ID number) (If an entire page is
not completed at one session, you will date any new entries and they will correspond to the CSN for that
date. Be aware that bill time is justified by information on the ICA and any major exceptions need to be
explained on the CSN. I.e.: 1 hour to complete SNAP.
6. Identifying Data: Age: type in; DOB: month = drop down box, type in day and year; gender, race, marital
status = drop down boxes; other identifying information = type in but is limited space (appearance,
identifying characteristics, physical characteristics – real or apparent height and weight (average, stocky,
healthy, petite), any physical deformities (hearing impaired, injured and bandaged right hand). Note basic
grooming and hygiene, dress- baggy, oversized, too tight, physically revealing, glasses or cap. Note
posture (slouched, erect), any noteworthy mannerisms, tics, or gestures
23.
24. Section B: Perceptions and History of Presenting Problem(s)
25.
□ Each source of information is to be addressed and include the name and relationship of the
person who gave the information. If in foster care the guardian will be DSS. The foster family’s information is
listed under Collateral Sources. Collateral Sources could also be information received from the referring person.
School input is collateral source.
26.
□ Ask each source of information the same question. If birth family is not available (in person or
phone) or consent (age 16 and above) to talk with them is not given you need to indicate this in the appropriate
block(s).
27.
□ Address all 4 blocks and each question within the blocks. Remember to review the Referral
Form and address issues identified on it.
28.
29.
Block 1: you are inquiring about the reason for coming in for treatment. Looking for
issues/problems (Px), psychiatric, emotional, behavioral symptoms (Sx), history (Hx) of problems, When did
they start? How long? Intensity? and any stressors? Use quotation marks to indicate his/her exact responses.
This is the start of determining the treatment plan. Need to elaborate on “my momma said I had to come”. Next
question would be “what is/was going on that momma thinks you need to come to the center?”
30.
31.
Block 2: Ask each (client, family and collateral) what is his/her thinks caused/triggered the
problem.
32.
33.
Block 3: Ask each what area(s) of the client’s life and who if anyone else is affected by the
client’s problem. How/Does the problem affect the client’s thoughts of him/herself, does this impact how the
others think of the client? Possible areas: family relationships, work, friendships, school performance.
34.
35.
Block 4: Ask each what they think will help make it better. This gives an indication of what they
want from the Center: medications, coping or relationship skills development, or anger management, behavioral
changes, etc. Ask if anything helped in the past, types of treatment, referrals, etc.
CAF ICA Form Page 2
Enter Name and CID # at top of pages 2 – 8 (by copying and pasting now – saves time)
!!!!!When working with children, all information should be asked of the child (if age appropriate) and
caregiver/parent/guardian. !!!!!!!
36.
37.
Section C: Urgent Needs/Risk Assessment
38. □
Risks: Ask about each area (suicidal, homicidal, self mutilation and other risk taking
behaviors), click appropriate blocks.
39. □
Comments: address any checked blocks (other than denies) in each risk question.
History of suicidal and/or homicidal/assaultive acts would go here. Note if affected by substance use.
40. □
Steps taken to address urgent needs: This is what is done at time of intake if urgent needs
82
are identified. Example: Referred to physician for immediate evaluation, assessment stopped to deal with
immediate safety issues, admitted to an inpatient facility, etc.
41.
42.
CAF ICA Form Page 2 (con’t)
43.
44.
Section D: History of Mental Health Treatment
45.
Client:
□ Click None if they deny having any prior MH Tx.
□ List any and all treatments the client has received in order of occurrence.
□ None if denies or List and describe any family history of mental health issues or treatment and relationship
Example: June 1982- Nov. 2002 - ABC MH Center, NY; Dx.-depression; Tx. type-monthly Dr. appts, for
medications; stopped Tx. due to moving out of state.
August 1999 - Inpt. Tx. @ Bellevue Hospital, for 3 weeks. Suicide attempt, overdose of antidepressants, and
depression, DBT and Zoloft; couldn’t afford outpatient follow-up.
Family:
□ Check none if they deny any family history
□ List the relationship and type of mental health problems, treatment, and Dx. if known.
CAF ICA Form Page 3
Section E: Trauma History
□ Each Center May or may not be participating in the Trauma Initiative. Reference to the Trauma
Assessment Form is done by checking the “See Trauma Assessment Form Check box”.
□ Check appropriate boxes if none is check for history and type of trauma then skip the “Was client” and
issues identified” sections. If trauma is identified then describe the issues/difficulties they are
“Describe
experiencing.
Section F: Substance Use
Check Boxes: Address/ask about each substance, if used indicate the age started, frequency and quantity,
method and last use. If admits to using some but not others fill in the info to the applicable ones and leave the
others blank. Example: Cannabis: 16yo, 1-2 joints/per weekend, smoked, 3 days ago. If denies any use check
the “Denies” block and go to Family Hx of substance abuse. (Item 5 under “Substance Use Treatment”)
Substance Use Treatment: enter all treatment episodes starting with date, include location, dates, type of
treatment and how and why ended. Use N/A or None Reported if applicable
Substance Use Experiences: Ask about each 1-5, if answer is yes, describe in the line beside the question.
CAF ICA Form Page 4
Section G: Medical History and Current Status
Some Centers use The Medical Assessment Form, which is a nursing assessment form. If the Medical
Assessment Form is completed this section does not have to be done. Refer to medical assessment form by
checking the block. The MAF will need to be completed within 3 scheduled visits. If any blocks are checked for
current or history they must be addressed in the comments section. Example: MVA -fractured left femur -2002;
head Injury from fall in 1999, etc.
Remember to ask for authorization to obtain medical information from hospitals and PCPs if applicable!!
Check the “C block” beside “No physical sx/problems” if they currently do not have any problems and leave the
other “C” blocks blank but you may check “H” Boxes since they could still have a history of certain ailments.
The Surgery and STD specify blocks, if applicable; information is to be entered in the comment section.
Skip to Significant Family History. Either fill in the family history if any (indicated the relationship) or type/write
in denies are none identified or does not know
Medication: List all medications prescribed and over the counter. Remember to ask about herbs and vitamins
List Medication Allergies and Adverse Reactions to medications
Primary Care Physician, phone number and date last seen. Who do they see for medical problems? When
entering the date last seen you must enter it as mm/dd/yy, if not it changes when tabbed to the next item.
83
If he/she does not have a primary care physician, indicate if community resources were given to the
client by checking yes or no. If yes, list the type of resources given. Example: “List of local physicians and
health care centers given:
CAF ICA Form Page 5
Section H: Social Economic and Cultural
Ask and address all questions and prompts. Do Not Leave Blanks - use denies or unknown, none or N/A as
appropriate.
1. What state/town born and raised?
2. Family of origin - natural parents-married, divorced, adoption, foster care, siblings, and extended family;
relationship current and past with family of origin.
3. Current family/significant relationships, parents, grandparents, and siblings describe relationship with
them. Girl/boy friends, role models
4. Past relationships- got along with others, always a loner etc
5. Significant losses/separations through war, divorce, death, limbs, eye sight etc.
6. Current housing arrangements…consider if they need assistance or referral in this area.
7. Ask about issues with sex/sexuality – list or denies any problems
8. Activities they enjoy with others- talking on phone, doesn’t like to be around others
9. Current religious involvement. Attends church 3x week,
10. Educational background if applicable, why he/she quit school, performance in school, any area of special
training/expertise.
11. Current & Past employment N/A or part time jobs- type of work he/she would like to do.
12. List any past & current legal issues pending court orders, charges, legal issues, adoption/custody issues.
Is treatment court-ordered? –be sure to indicate on page 1
CAF ICA Form Page 6
Section I: Child and Adolescent
Developmental History - Check appropriate boxes
□ Source of data if other than mother: fill in the name and relationship
□ Prenatal: Questions are regarding pregnancy
□ Birth: Questions apply to childbirth
□ Infancy: Questions apply from birth to 2 years old
□ Early Developmental Stages: check the appropriate box –
□ Major losses/separations: check yes or no box. If yes then document the ages events occurred and the
loss. Note other info as needed.
□ Medical Issues: any yes answers need to indicate if past or present. List the type of exposure or childhood
illnesses, if any.
CAF ICA Form Page 7
(Information should be obtained from adult, client, and school staff as appropriate).
School History
□ Check N/A if not in school otherwise ask each question and check accordingly
Behaviors
□ Check all that apply at home and/or at school
Check type of discipline and describe
Social Environment
□ Peer interactions: How do they get along with others and what age are peers?
□ Who is the current caregiver and what is the relationship? (Parents, foster parents, grandparents)
□ List any issues regarding caregiver/living situation
84
□ Who has legal custody (parents, mother/father – joint, DSS, etc) Include visitation issues
CAF ICA Form Page 8
Section J: Strengths, Needs, Abilities, and Preferences
(SNAP is client's words (some need help to identify) FYI these prompts are more specific than the ones on the
POC which are more global.
Strengths: support (family, social, spiritual), hobbies, neighbors, teacher, caregiver, employer, enjoys sports
and reading, other agency, etc) and attitudes that have helped in the past.
Desire to succeed, cooperative, motivated, receives guaranteed income, etc.
Needs: emotional, physical, social, environmental. Hearing impaired, transportation, vocational training and/or
placement, to complete education, recreational or social outlets, friends, role model, on-going medical care for
medical problems, housing, legal assistance, A&D treatment, etc. energy outlet.
Abilities: ability to follow up with treatment, understand instructions, participate in treatment, follow directions,
drivers license, can read & write, takes medication per instruction, abstains from ETOH/drug use, vocational &
avocational skills, good computer skills and games, starting pitcher for baseball team, spells well, etc.
Preferences: outpatient vs. inpatient treatment, appointments certain days or time of day, frequency, male vs.
female casemanager, medications vs. no medications, denominational, cultural, etc.
Section K: View of Treatment and Discharge
Client’s expectations: What client wants to happen; and what they expect from treatment; these are the
foundation for the goals on the ITP.
Family’s expectations: Same as above but from the Caregiver’s perspective if applicable. Willing to be
involved in treatment, need referral to support group, Federation of Families/NAMI, education regarding mental
illness? Name the family member and relationship.
Client’s commitment and motivation to treatment: The motivation will give insight into the commitment to
follow the treatment plan and medication compliance and indicative of the outcomes. Use the motivation and
depth of commitment when developing the POC. “Is the person willing to come to appointments as scheduled
and participate in treatment process via working in sessions and doing outside assignments/homework?”
Family’s commitment and motivation to treatment: How can they best help the client, indicates willingness
to support the client and themselves to learn skills and /or behaviors to address the issues.
Client’s and Family’s Discharge Criteria: What will be different or what must happen for him/her to no longer
need center services? Very important, this needs to be jointly identified whenever possible. Sometimes an
individual may need continued support / services from the Center but to varying degrees. (“Discharge is not
appropriate but treatment (intensity and frequency) will be adjusted to the identified needs.”) Be specific about
what needs to be different or how they will know and measure they are ready for discharge: “I learn out to stay
out of trouble at school – no suspensions”. “My child will go from failing all subjects to making C’s.” “No more
legal problems.” “I get a job.” “I stop crying for no reason.” “8 weeks without in school suspension or discipline
notes”. These can be broken down into smaller objectives for the ITP. “Ask the person, what will your
life/circumstances/sx look like when you are ready for transition to less frequent/intense services and/or
discharge?”
Section L: Mental Status Exam
Any blocks checked that are not normal range or response can be elaborated on in the comment section.
Appearance and Hygiene: Check appropriate descriptor and write in when indicated (dress, gait, posture, eye
contact, nutritional status, etc.)
Motor Activity (check appropriate descriptor)
Attitude During The Interview (check appropriate descriptor)
85
Affect (check appropriate descriptor) how they felt a given moment (comments can include: “consistent with the
content of the conversation and facial expressions”, “cried while discussing recent happy event and unable to
explain why”.
Mood (check appropriate descriptor) how they feel most days. Note level of emotion dysregulation and
behaviors that indicated it, ways the client has handled it.
Speech (check appropriate descriptor)
CAF ICA Form Page 9
Thought Process: (check appropriate descriptor)
Difficult to understand line of reasoning, confabulations, illogical thinking, grandiosity, magical thinking,
perseveration, delusions, reports of experiences of depersonalization). Abstraction Skills
These are based on proverbs, sayings, similarities ("How are a ______ and a ______ alike? Different?"), and
giving both definitions for word ("What are two different meanings for the words 'right,' 'bit,' and 'left'?")
Examples of proverbs and sayings are: ("What do people mean when they say... A rolling stone gathers no
moss, All that glitters is not gold, Don't count your chicken before they hatch, Don't put all your eggs in one
basket, Strike while the iron is hot, Rome wasn't built in a day, When the cat's away the mice will play, A stitch in
time saves nine.") What would I mean if I said I am feeling blue? Seeing red? I have a chip on my shoulder? Hot
under the collar?
Thought Content: (check appropriate descriptor) If suicidal/homicidal – see the risk assessment pg. 2.
Describe, including plans and intent. Are there things that worry you a lot? Have you ever felt an intense fear or
worry that something bad would happen to you? Are there specific things that frighten you? (anxiety) Do you
ever feel the need to do something over and over until it's perfect? Are there certain things you sometimes feel
compelled to do over and over? Are there ever thoughts that you just can't get out of your head? (Compulsions
and Obsessions) Hallucinations: check any/all that apply and describe.
Delusions: check any that apply and describe if other than no evidence
Orientation/Level of Consciousness: Check all that apply
Judgment: (check appropriate descriptor)
Insight/Adjustment to Problems/Illness, Disabilities, Disorders: check appropriate descriptor
Memory: Check the appropriate box. Document (in comments) the test to assess memory. Intact or document
incorrect responses which indicate difficulties with memory. Recent Past: after ten minutes ask client to repeat
the name of the four objects, ask what they did yesterday (meals, activities, etc.) Remote Past: ask birthday,
dates of school attendance, and other important chronological facts. Immediate: (Registration and Recall) name
four objects and ask client to repeat them
Concentration and Calculations: check the appropriate box. Document the test(s) (in comments) and
result/answer. Ability to pay attention: does Client ask you to repeat questions?
Based on Digit Span and attention to your questions, serial 7's or 3's in which they count backwards from 100 to
50 by 7s or 3s, naming the days of the week or months of the year in reverse order, spelling the word "world",
their own last name, or the ABC's backwards)
Fund of knowledge; check the appropriate box. Document the test(s) and results/answers (in comments).
Problem-solving ability, estimate of general level of intellectual functioning, based on answers to questions like
"name last four presidents," "who is the governor of the state," "what is the capitol of the state," "what direction
does the sun set," etc...) Results of testing, if any and who did the testing: IE: IQ testing score and who did it
Other Pertinent Information: complete as needed or N/A. Note impulsivity (low, medium, high, affected by
substance use). Do you ever find yourself suddenly doing something before you have really had a chance to
think about it? Do you ever do things you had decided not to do, and don't know why? Does money "burn a hole
in your pocket"? Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled,
happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such)
Sleep Patterns: How are you sleeping? Do you have trouble falling asleep, staying asleep, waking up? Note:
Some antidepressants work best with clients who have trouble falling asleep, while others work best with those
who can't stay asleep or wake up.
86
Appetite/Eating Patterns: How is your appetite? Do you think your eating habits are unusual? What is your
weight now? What is the most and least you've weighed? Are you concerned about your weight? (Eating
Disorders)
Energy Levels: How is your energy level though the day; do you have enough energy to get things done?
Have you ever had so much energy you couldn't sit still? That you didn't need to sleep for days at a time?
(Mania)
Libido: N/A if not age appropriate.
CAF ICA Form Page 10
Section M: DSM-IV Diagnosis
Axis I: Specify numerical code and name of disorder as appears in DSM-IV
*If applicable, note severity/psychotic/remission/chronicity specifiers
*Insure that diagnosis given meets DSM-IV diagnostic criteria for that diagnosis and document all
supporting
symptoms that the client presents/reports.
Axis II: DSM-IV numerical code and name of disorder (or absence of)
Must include code; do not use >rule-out= if no diagnosis note V71.09 or if deferred Diagnosis use 799.9
You
can also note either of these two codes if there are symptoms of an axis II
diagnosis but not sufficient to meet
diagnostic criteria. In this case, also write in the observed traits.
Example: 799.9 Borderline Personality Traits.
Axis III: State general medical conditions (e.g. diabetes)
Axis IV: State psychosocial and environmental problems (e.g. divorce, loss of job)
Axis V:
GAF score at time of assessment. GAF score to be submitted to clerical to be entered into CIS. .
Section N: Interpretive Summary
The blocks in the heading are to be checked when that information is included in the body of the summary. It is
a way to insure that it is included. These are areas that have been identified as frequently missed.
Interpretive Summary/Clinician’s Expectations:
This is a narrative summary and interpretation of all pertinent assessment data such as: demographic factors,
medical issues, past treatment history, reason for seeking services, mental status, motivation, support, positive
and negative factors, levels of functioning, and co-occurring disorders.
This summary is the beginning of treatment, justifies the treatment/services rendered, and it is the foundation of
the POC. Issues defined here are incorporated into the POC. Include the MHP’s recommendations for
treatment and possible referrals. Include all factors that may impact the outcomes, positive or negative.
Frequently, when a Client first enters our services they “just want to feel better” or “not go to the hospital
anymore” or “behave and mind their parents and or teachers” they need us to guide them into setting obtainable
goals and objectives. This summary will be the foundation to jointly plan their treatment and is the basis for the
diagnosis. A miscellaneous sheet may be used for continuations.
If this form is used as part of the documentation for billing the CSN should be referenced. Example: At
the bottom of section M include: “See CSN # ________ dated________” the CSN will also reference this
form.
Assisting Staff’s Signature/Title and Date: If another clinician assists in gathering some of the information
they are to sign in this block.
Clinician’s Signature/Title and Date: The MHP who minimally completes sections: B, C, E, I, J, K, L, and M
but reviews the data to complete section M.
H:\TRAINING QA\ICA 2006 CAF INSTRUCTIONS DRAFT 3.DOC
Carolyn Cohen 9/6//06
87
BERKELEY COMMUNITY
MENTAL HEALTH CENTER
Initial Clinical Assessment
Date:
Source of Data:
Referred By:
Court Order: (Type)
Self
Client
School:
Old records
Family:
Other:
Other:
Section A: Identifying Data
(First)
Name:(Last)
Age:
DOB:
Gender:
(MI)
Race:
CID#
Marital Status:
Other Identifying Information:
Section B: Perceptions and History of Presenting Problem(s)
Documentation should address the source of information and the following:
(1) What brought client here today (px, sx, hx, duration and stressors)?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
(2) What are the possible causes? Why does the client think she/he is having these problems/symptoms?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
(3) Who and what area of client’s life are affected by this? How does this make client/family member feel about him/herself?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
(4) How does client/family think this can be solved? What will help?
Client Response:
Family/Guardian (Specify):
Collateral Sources (Specify):
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184 (FM AUG 09 06)
PAGE 1 OF 10 (CAF ICA)
Name:
CID#:
Section C: Urgent Needs/Risk Assessment
Suicidal Risk:
Denies
Ideas
Plans
Means
Intent
Hx of attempts
Hx in family
Homicidal Risk:
Denies
Ideas
Plans
Means
Intent
Hx of attempts
Hx in family
Self Mutilation:
Denies
Ideas
Plans
Means
Intent
Hx of attempts
Hx in family
Other Risk Taking Behaviors:
Past or current (Specify in comments section.):
Driving fast/DUI
Unprotected sex
Gang affiliations
Denies
Fire setting
Hx of violence
Other
Comments:
Steps taken to address urgent needs:
Reviewed emergency procedures with client/family
Identified emergency contacts: 211
Family
Friend
Other
Developed Personal Safety Plan:
Identify triggers and warning signs that may lead to escalating behaviors/Crisis:
Identify coping skills the client has that can be utilized to prevent crisis:
Preferred interventions for de-escalating behavior/crisis:
Section D: History of Mental Health Treatment
A chronological history of all inpatient and outpatient treatment to include location, date of treatment, diagnosis, type of treatment,
and how/why ended.
None
Family Mental Health History:
None
Describe history and specify relative:
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
PAGE 2 OF 10 (CAF ICA)
Name:
CID#:
Section E: Trauma History
See Trauma Assessment Form)
None apparent
Signs/sx present, but denies
Acknowledges
Referred for assessment
History of Trauma/Violence/Abuse/Neglect:
Type of Trauma/Violence/Abuse/Neglect:
None
Sexual
Natural Disaster
Was client:
Victim
Witness
(
Physical
Emotional
Self/someone else was going to die/be killed
Accident (specify):
Perpetrator
Describe issues identified: (nightmares, flashbacks, startle reflex, avoidance):
Section F: Substance Use
Denies (go to Family Hx of Substance Abuse)
Substance
Age Started
Frequency/Quantity
Method
Last Use
Alcohol
Cannabis
Sedatives (Benzodiazepines, Barbiturates)
Stimulants (Crack, Cocaine, Methamphetamine, Speed)
Hallucinogens (LSD, Mushrooms, Mescaline)
Opiates (Heroin, Codeine, Morphine)
Inhalants
Steroids
Caffeine
Nicotine
Other
Substance Use Treatment (A chronological history of all inpatient and outpatient treatment to include location, dates of treatment,
type of treatment, and how/why ended.):
Substance Use Experiences:
1) Experienced blackouts?
Yes
No If yes, describe:
2) Withdrawal symptoms (seizures, DT’s, etc)?
3) Legal involvements related to substance use?
Yes
Yes
No If yes, describe:
No If yes, describe:
4) Is your alcohol/drug use something that needs to be addressed in treatment?
5) Family history of substance abuse?
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
Yes
Yes
No If yes, describe:
PAGE 3 OF 10 (CAF ICA)
No If yes, describe:
Name:
CID#:
Section G: Medical History and Current Status
C
C = Current problem
C
H
H
(
See Medical Assessment Form)
H = Client has a history
C
H
No physical sx/problems
Kidney/bladder problems
STDs (specify)
Thyroid
Stomach/intestinal problems
Other (specify)
Seizures
Serious body/head injury
Severe headaches/migraines
Heart problems/Hypertension
TB
Epilepsy
Date of last menstrual period :
Cancer (specify):
Liver/Hepatitis
Pregnant?
Lung problems
Immune disorder
# of pregnancies
Diabetes (specify if juvenile or adult
Surgeries (specify)
# of living Children
onset)
Allergies:
Females:
Yes
No
Comments: (Describe status of any current physical conditions. Describe any significant history.)
Significant Family History:
Medication: (List all current medications: prescribed and OTC, including herbs, vitamins, etc.):
Name of medication
Dosage
Frequency
Why prescribed?
Medication Allergies:
Adverse Reactions to Medication:
Primary Care Physician:
Phone #: (
If none, community resources provided?
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
Yes
)
-
No
PAGE 4 OF 10 (CAF ICA)
Date Last Seen:
How well does it work?
Name:
CID#:
Section H: Social, Economic and Cultural
1). Where were you born and raised?
2). Describe your family of origin (who raised you, how many sibling(s), quality of relationships then and now):
3). Describe current family/significant relationships (significant other? children? quality of relationships?):
4). Describe past significant relationships (marriages, divorces, separations, etc.):
5). Describe any significant losses/separations of any family members/significant others (including loss of pets, physical functions,
limbs, property/possessions, etc.):
6). Describe current housing situation (house, mobile home, boarding homes, shelter, homeless, etc.): Any needs?
7). Any problems/issues/changes with sex/sexuality?
Yes
No
(If yes, describe):
8). Describe current social involvement (activities that you enjoy with others):
9). Describe current spiritual/religious involvement:
10). Describe educational background (how far in school, tech school, college, special ed., special programs, highest level completed):
11). Describe current and past employment (how long at each job, if on disability, include any military service/type of discharge, etc.):
If you could work now, what would you be interested in doing?
12). History of legal involvements (DJJ, charges, jail/prison time, #arrests and #convictions, as well as any current legal problems):
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
PAGE 5 OF 10 (CAF ICA)
None
Name:
CID#:
Section I: Child And Adolescent
Developmental History
Source of data if other than birth mother:
Prenatal: Mother’s condition while pregnant with the child
Normal, no health problems
Unknown
Threatened miscarriage
Diabetes
Frequent nausea/vomiting
Pregnancy was:
Planned
Use of Alcohol:
None
Infrequent
Use of Nicotine:
None
Less than one pack/day
Use of Illegal drugs:
None
Infrequent
Use of Prescription/OTC drugs:
Bleeding
Toxemia
High BP
Unplanned
Yes
Frequent
More than one pack/day
Other use
Frequent specify:
No specify:
Comments:
Birth: Child’s status at time of birth
Normal
Unknown
Birth trauma (forceps, breech, prolonged/early labor, cord problems, hypoxia, etc)
Single birth
Multiple birth
Low birth weight
Premature
NICU
C-Section
Other complications
Comments:
Infancy: Birth to 2 years
Contented/happy
Unknown
Colic
Excessive crying
Overactive
Failure to thrive
Feeding problems
Comments:
Early Developmental Stages: W=Within Normal Limits D=Difficulty
W D
W D
Motor skills (crawling/walking)
Hearing
Vision
Toilet training
Cognitive development
Unknown
W
D
Speech development
Language development
Comments:
Has the child had any major losses/separations from family members/significant persons?
Give approximate age of child and additional information if available:
Medical Issues (specify past/current/complications):
Yes
Unknown
No
Regular pediatric preventive (well-baby) care
Immunizations current
Enuresis
Encopresis
Exposure to toxins (i.e. lead, asbestos, etc.) list:
Childhood illnesses (measles, mumps, chickenpox, etc.) list:
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
Page. 6 of 10 (CAF ICA)
Yes
No
Name:
CID#:
School History
School attending:
Type of class:
N/A
Grade:
Regular/mainstream
Teacher(s):
Resource
Gifted
LD
EH
TMH
EMH
Self-contained
Subject(s)
Rehabilitative/Support Services:
None
PT
OT
Speech
Attendance:
Regular attendance
Misses often/excused
Reason for absences:
Illness
Other specify:
Need for discipline:
None/infrequent
Grades repeated:
No
Performance:
Exceeds
Truancy
Frequent
Other, specify:
Misses often/unexcused
Office referrals
ISS
OSS
Expulsions
Yes specify:
Average
Below average
Extracurricular activities:
If available, would child/parents be willing to participate in school based services?
Behaviors (Check all that apply)
H=Home
H
S
H
Yes
No
See CBCL Report
S=School
S
H
S
Appropriate, no problems
Runs/climbs inappropriately
Often defiant
Unable to concentrate, focus
“On the go” or seems driven
Deliberately annoys people
Makes careless mistakes
Talks excessively
Blames others for mistakes
Difficulty sustaining attention
Often blurts out answers
Touchy/easily annoyed
Fails to finish tasks
Difficulty waiting
Angry/resentful
Difficulty organizing
Interrupts/intrudes on others
Spiteful/vindictive
Dislikes complicated tasks
Often loses temper
Bullies/threatens/intimidates
Loses things
Often argues with adults
Initiates physical fights
Easily distracted
Often lies
Used weapon to harm others
Often forgetful
Steals
Cruel to animals/people
Often fidgets/squirms
Fire setting
Destruction of property
Leaves seat inappropriately
Violates curfew
Truancy
Excessive anxiety concerning
separation from caregivers
Irritable
Oppositional
Disrespectful
Seems depressed/down
Discipline at home:
Restriction of activities
Peer interactions:
Sociable
Time out
Spanking
Other: Describe:
Social Environment
Few friends
Same age
Younger
Older
Isolated
Current caregiver and relationship to child:
Issues/concerns re: caregiver/living situation:
Legal custody:
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
Page 7 of 10
(CAF ICA)
Name:
CID#:
Section J: Strengths, Needs, Abilities, and Preferences
Strengths: (family, social, spiritual support, hobbies, and attitudes
that have helped overcome past crises)
Needs: (Client’s expression of current needs emotional, physical,
social, environmental)
Are you currently receiving services from other providers/agencies?
Yes
No
Specify:
Abilities: (Client’s ability to follow up with treatment, understand
instructions, participate in treatment)
Preferences: (appt., day/times, therapist, treatment modality, etc.)
Section K: View of Treatment and Discharge
Documentation should include the source and the following:
¾ What are your expectations?
Client:
Family (specify):
¾ What is your commitment and motivation to treatment?
Client:
Family (specify):
¾ How will you know when you will be ready for discharge?
Client:
Family (specify):
Section L: Mental Status Exam
List more than one descriptor if applicable. Elaborate on any problem areas in the space provided.
Appearance & Hygiene
Motor Activity
Meticulous
Comments:
Neat
Appropriate to situation
Clean
Disheveled
Over-active
Bizarre
Tremor/tics
Body Odor
Poor coordination
Repetitive
Lethargic
Comments:
Attitude During Interview
Affect
Cooperative
Comments:
Oppositional
Appropriate to situation
Hostile
Blunted
Dramatic
Flat
Guarded
Tearful
Irritable
Incongruent
Withdrawn
Expansive
Labile
Comments:
Mood
Happy
Euthymic
Anxious
Depressed
Angry
Hopeless
Suspicious
Passive
Comments:
Speech
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
Normal rate and tone
Comments:
(FM AUG 09 06)
Slow
Fast
Soft
Loud
PAGE 8 OF 10 (CAF ICA)
Pressured
Slurred
Stuttering
Alogia
Name:
CID#:
Thought Process
Normal, appropriate, coherent, relevant
Loose associations
Circumstantial
Tangential
Indecisive
Disorganized
Flight of ideas
Concrete
Blocking
Racing
Comments:
Thought Content
Normal
Phobias
Obsessions
Ideas of hopelessness
Ideas of worthlessness
Paranoia
Persecutory
Suicidal
Homicidal (Note: If suicidal or homicidal, see risk assessment)
Comments:
Hallucinations
No evidence
Auditory
Command
Visual
Olfactory
Tactile
Denies
Comments:
Delusions
No evidence
Persecutory
Grandeur
Reference
Influence
Somatic
Denies
Comments:
Orientation/Level of
Consciousness
Alert
Oriented to
Clouded
Confused
Person
Place
Time
Situation
Comments:
Judgement
Able to make sound decisions
Usually able to make sound decisions
Poor decision making, adversely affects self
Poor decision-making, adversely affects others
Comments:
Insight/Adjustment to
Problems/Illness,
Disabilities, Disorders
Denies problems/illness
Blames others
Acknowledges but fails to understand
Minimizes
Acknowledges & understands
Comments:
Memory
(use example )
Intact
Poor remote
Poor recent
Poor immediate
Comments:
Concentration &
Calculations
(use example)
Able to concentrate
Able to do simple math
Easily distracted
Daydreams
Comments:
Fund of Knowledge
(use example)
Above average
Average
Below average
Comments:
Other Pertinent Information:
Sleep Patterns:
Appetite/Eating Patterns:
Energy Levels:
Libido
Adequate
Hypersomnia
Adequate
Purges
Adequate
Adequate
Early awakening
Insomnia
Increased
Binges
Increased
Increased
Short intervals
Sleepwalking
Decreased
Doesn’t eat
Decreased
Decreased
Nightmares
Decreased need for sleep
Weight changes:
Lbs.
Other
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
PAGE 9 OF 10 (CAF ICA)
Fatigue
Name:
CID#:
Section M: DSM-IV Diagnosis
(Must include both code and description)
Axis I:
Criteria For Dx:
Axis II:
Axis III:
Axis IV:
Axis V:
Section N: Interpretive Summary
This is a narrative of the data gleaned during the assessment. It should include:
disorders
Justification for treatment
Priorities for treatment, include co-occurring
Recommendation(s) for treatment and referrals (including services and their frequencies)
Clinical judgement re: both positive and negative factors likely to affect the client’s course of treatment and clinical outcomes.
And it could also include:
diagnosis
Current levels of cognitive, emotional, and behavioral functioning
Issues present
Adjustments to disorder/disabilities.
Assisting Staff’s Signature / Title (if applicable):
Date:
Clinician’s Signature / Title:
Date:
SCDMH FORM
MAY 2005 (REV AUG. 2006) C-184
(FM AUG 09 06)
PAGE 10 OF 10 (CAF ICA)
Basis for
BERKELEY COMMUNITY MENTAL HEALTH CENTER
MEDICAL ASSESSMENT FORM
Circulatory
High blood pressure
Yes †
No †
No Infor †
Medication:
Stroke
Yes †
No †
No Infor †
Date:
Phlebitis (blood clots
in arms/legs)
Yes †
No †
No Infor †
Location:
Unusual bleeding
Yes †
No †
No Infor †
Location:
Family Hx, if appropriate:
Cardiac
Chest Pain
Yes †
No †
No Infor†
Family Hx, if appropriate:
At Rest:
Upon Exertion:
Heart attack
Other Heart disease
(Congestive heart
failure, Valve
problems, etc.)
Yes †
No †
No Infor†
Yes †
No †
No Infor†
List:
Specify illness:
Date(s):
Medications:
Respiratory
Family Hx, if appropriate:
Asthma
Yes †
No †
No Infor†
Medication:
TB (past or present)
Yes †
No †
No Infor†
Medication:
Chronic Cough
Yes †
No †
No Infor†
Productive †
Non Productive †
Blood Present 
Lung disease
(COPD, etc.)
Yes †
No †
No Infor†
List:
Malignancies
Cancer (past or
present)
Yes †
No †
No Infor†
Family Hx, if appropriate:
Location:
Treatment:
Musculoskeletal
Arthritis
Yes †
No †
No Infor†
Location:
Medication:
Fibromyalgia
Yes †
No †
No Infor†
Medication:
Fractures
Yes †
No †
No Infor†
Requires Aid with
Ambulation
Yes †
No †
No Infor†
Location:
Family Hx, if appropriate:
Dates:
Walker:  Wheelchair  Crutches 
___________________
________________________
________________ Date
______________________
CID#
Client Name
- 98 -
Genito-Urinary
Family Hx., if appropriate:
Kidney Disease
Yes †
No †
No Infor†
List:
Recurrent Bladder
Infections
Yes †
No †
No Infor†
Medication:
Difficulty urinating
Yes †
No †
No Infor†
Kidney Stones
Yes †
No †
No Infor†
Dates:
Venereal Disease
Yes †
No †
No Infor†
Type:
Dates:
Impotency or
Sexual Dysfunction
Yes †
No †
No Infor†
Type:
Frequency:
Pregnant
Yes †
No †
No Infor†
Trying: Yes † No †
Menstrual Problems
Yes †
No †
No Infor†
Last cycle:
Gastrointestinal
Ulcers
Yes †
No †
No Infor†
Medication:
Irritable Bowel
Syndrome (IBS)
Yes †
No †
No Infor†
Medication:
Constipation
Yes †
No †
No Infor†
Remedies used:
Loose Stools
Yes †
No †
No Infor†
Remedies used:
Abdominal Pain
Yes †
No †
No Infor†
Remedies used:
Chronic
Heartburn/Reflux
Yes †
No †
No Infor†
Meds/Remedies used:
Gallbladder disease
Yes †
No †
No Infor†
How treated:
Family Hx
Endocrine
Diabetes
Yes †
No †
No Infor†
Onset: Juvenile †
Adult †
Insulin Dependent: Yes † No † Type
Family Hx:
Oral Agent: Yes † No † Type
Diet Controlled: Yes † No † Type
Yes †
Thyroid
No †
No Infor†
___________________
________________________
________________ Date
______________________
CID#
Client Name
- 99 -
Neurological
Seizure Disorder
Yes †
No †
No Infor†
Family Hx:
Medication:
Neurologist:
Head Injury
Yes †
No †
No Infor†
LOC  How long?_________ Dates:
Developmental
Disability
Yes †
No †
No Infor†
Mental Retardation: Yes † No †
Attention Deficit Disorders: Yes † No †
Learning Disabilities: Yes † No †
Spine Injury
(Paralysis)
Yes †
No †
No Infor†
Type:
Onset:
Hepatic
Liver Disease
Yes†
No †
No Infor†
Jaundice (yellowing of skin or eyes) 
Hepatitis: A  B  C  O 
Cirrhosis 
Other : ______________________
Date of Onset:
Medication/Treatment:
Pancreatitis
Yes†
No †
No Infor†
Dates:
EENT
Glaucoma
Yes†
No †
No Infor†
Medication:
Cataracts
Yes†
No †
No Infor†
Right †
Yes†
No †
No Infor†
Corrective Lens
Yes†
No †
No Infor†
Glasses †
Difficulty swallowing
Yes†
No †
No Infor†
Date of onset
Chronic ear aches
Yes†
No †
No Infor†
Date of last episode:
Hearing
Yes†
No †
No Infor†
Deaf: Total ___ partial __
Chronic
headaches/migraines
Yes†
No †
No Infor†
Treatment/Medications:
Blurred vision
Left †
Contacts †
Meds:
Special Diet
Sleeping habits
Do you fall asleep during the day?
Yes † No †
Have you been told that you stop breathing during sleep?
Other Systems
Have you ever been tested for HIV?
Immunization
Current? Yes † No †
Do you snore loudly? Yes † No †
Yes † No †
Yes † No †
Other Not mentioned
above:
___________________
________________________
________________ Date
______________________
CID#
Client Name
- 100 -
Vital Signs:
Height: __________________
Pulse: ____________
(Sitting): _____________
BP
Weight: _________________
Respirations: ______
(Standing): ___________
BP
Past surgical procedures and medical hospitalizations: ____________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Current medication (Medical): ________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Current/Past Medication (Psychiatric): ________________________________________________________________________
(What have you been tried on as well as what you are taking now?)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Over the Counter Medication: ________________________________________________________________________________
___________________________________________________________________________________________________________
Allergies: __________________________________________________________________________________________________
___________________________________________________________________________________________________________
Medication Adverse Reactions: _______________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Nursing Education Provided: Yes † No †
Type: ________________________________________________________________
Do you have a Primary Care Physician: Yes † No † Name: ___________________________________ Phone #: ________
Name of Practice: _____________________________________________ Address:______________________________________
Referred to Primary Care Physician for: _______________________________________ Yes † No †
_________________________________________________
Staff signature and Title
___________________________
Date
BERKELEY COMMUNITY MENTAL HEALTH CENTER
Hospital Discharge Assessment Form
Name:
CID #:
Was BCMHC involved in admission?  Yes
 No
Hospital Admission Date:
Hospital Discharge Date:
Name of hospital consumer admitted to:
Did hospital send Discharge summary?  Yes
 No
Diagnosis (current; was this changed in the hospital?):
Mental Status: (appearance, affect, mood, judgment, perceptual disorder, insight, etc)
Medications (name, dosage, etc; neuroleptic consent needed? Was the consumer given facts about meds
while in hospital? What is the consumer’s understanding of why the meds were RX’d?):
Side Effects? (AIMS if needed)
Hospital experience (How was your hospital experience? Was it helpful? Did anything upsetting or
frightening/scary happen? What? Include time from transport through discharge)
Rate the hospital experience 1-10 (1=worst experience of my life; 10=very helpful, positive experience):
Plan: (next appointment, Dr. appt., additions to treatment plan)
Clinician signature/date:
BERKELEY MENTAL HEALTH CENTER
Clinical Assessment Update
List only the changes from the ICA or last update.
Date: __________________ Source of Data: □ Client
□ Family:___________ □ School:________________________________
□ Old records □Other:_________________________________________________
Section A: Identifying Data
Client Name: ________________________________________CID:
Updates (e.g. marital status, physical appearance, etc.):
________________
Section B: Current Psychiatric Status
Describe current psychiatric status & list any significant changes including: psychiatric inpatient treatment, symptoms,
problems, stressors & changes/additions in Axis I & II dx (may include MSE).
Section C: Urgent Needs/Risk Assessment
† Denies
Identify & describe:
Steps taken to address urgent needs:
Section D: Trauma
† Denies
List changes in trauma information including type of trauma & resulting symptoms:
Section E: Substance Use
Substance
Frequency/Quantity
Method
† Denies
Last Use
List all substance use treatment since last update including both inpatient and outpatient:
Comments
Section F: Medical
List any significant physical health changes since last update including hospitalizations, changes/additions in Axis III dx,
seizures, illnesses, allergies. † Denies
† See PMO for current medications. † NA
Change in primary care physician? † Denies or
Name:
Section G: Social, Economic and Cultural
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Comments:
Phone #:
Changes in the following: (Please elaborate on any “yes” answers in the comment section below.)
Employment/education
□ Yes □ No Loss/separation
Living arrangements
□ Yes □ No Legal status
Family/social relationships
□ Yes □ No Individualized needs, abilities, aptitudes, and/or skills
Custody/guardian
□ Yes □ No Other providers/agencies involved
Section H: Recommendations for Changes/Additions to Treatment
See † Progress Summary dated:
† CSN dated:
Center Use:
Assisting Staff’s Signature/Title:
Date:
Clinician’s Signature/Title:
Date:
SECTION 16
Plan of Care
Progress Reviews
The Plan of Care serves as the client’s roadmap to recovery. Keep it mind it must be a tool used to guide to the
client’s goals and justify the treatment according to diagnosis and promote recovery. The client must sign the
document or you must justify why they were unwilling or unable to sign. Every client must have a treatment plan if
they are to be in ongoing treatment. Clients that receive only emergency services do not have to have a formal
treatment plan.
The POC must be formulated, signed by the clinician and doctor within 90 days of admission. There must be a
yearly update of services/goals/objectives that will be signed and dated by the physician and clinician and client.
POCs may be done 30 days in advance of the anniversary date and listed “effective date: ________”. You may not
do this after the date due and make it effective when it was due. Your POC reports will help you keep track of
what clients are due for the updated POCs.
Any services delivered after the 90 days from admission must be no charged. Services required to be listed on the
POC and delivered after renewal POCs are due are to be no charged. Only those services which are not required on
the plan or care may be delivered and billed for. These services are: PMA, Nursing Services, TCM, CM, SPD,
Med Administration, and Assessment. Billing may resume once the physician signs the POC.
If services are added to the POC after the physician signs it, the physician must initial and date the added service to
show medical necessity. If this does not happen, the service must be no-charged.
The following information is provided to help you with the documentation of your goals and objectives:
Goals and Objectives
Three types of goals:
1.
Life goals: Include aspect’s of person’s life where they have hopes for overall improvement and may
include aspirations such as, “I want to be married” or “I want a job.”
2.
Treatment goals: Include the resolution of needs and concerns that are a barrier to discharge or
transition from services. They are often linked to the reason the person/family sought help. “I don’t
want to go to the hospital anymore” or “I want the sadness to go away” or “I want to be able to manage
my life again.”
3.
Quality of life enhancement goals: Includes those other needs not immediately related to seeking
services but typically reflect quality of life concerns for the individual or family. “I want to be able to
travel more” or “ I want more friends, a better job, live near the beach”, and so on. These goals are
often very important to the person, but not as tightly linked to needs, challenges and barriers that result
from mental health and addictive disorders that are the focus of the plan.
Language of goals: Goals should be in the client or family’s own words, use quotes
Criteria
Possible Goals
Provide a focus of engagement/life changes
“I want to get off drugs.”
as a result of treatment
“I want a boyfriend/girlfriend”
Are consistent with a desire for recovery,
Self determination, and self management.
I want to learn how to…….
I want to be able to drive a car.
I want to open my own bank account
Reflective of the person’s values, lifestyles
and so on
Culturally relevant, in consultation with
Individuals and their families
Appropriate to the individual’s age
Based upon the individual’s strengths,
needs, preferences, and abilities
Written in positive terms, which embody
hope, not negative in focus
Appropriate to the stage of recovery
Alternative to current circumstances
I want to work as …………
I want to live with my family
I want my family to accept me
I want to stop getting in trouble with
my parents
I want to be able to stay at home
with my family
I want to get through the school year
I want to find out why I keep getting
sick
I hope to live in my own apartment
I want to keep my job
I want to get the judge off my back
(pre-contemplation).
I want to feel better by stopping
grieving over my
husband’s/wife’s death
I want to feel better by not hearing
voices when I try to relate to people.
How to elicit goals:
Ask questions like:
1.
What would you like to change in your life? How do you want your life to be in the future?
2.
What is important to you? What are your hopes and dreams?
3.
Tell me about your friends, hobbies, favorite activities.
4.
What kind of work would you like to do?
5.
What keeps you from doing the things you would like to do/used to do?
6.
If court ordered or just don’t feel they have any problems—What does the judge say has to change for
your order to be dropped? What kinds of things does the judge/your family identify as a problem for
you?
KEEP IT SIMPLE:
One or two long term goals is plenty to work on. Make the objectives the short term things that the individual can
be successful with. Each objective and its intervention should build on the individual’s strengths, and resources to
address, relieve, and remove barriers to success that are immediately related to mental health and/or addictive
disorders.
For example: The person identifies that they like to garden and they like to write. The goal is “I want to stop losing
my temper with my family so much.”
An objective could be: Utilizing cognitive therapy, Joe will be able to identify triggers for his anger and will
substitute activities such as gardening and journaling to decrease his angry outbursts as evidenced by no more than
3 angry outbursts within each week in the next 3 mo as reported by Joe and his family.
Objectives: Should be described in action words and should not involve changes in thinking, understanding,
insight, etc. Objectives should require the individual and family to master new skills and abilities that support them
in developing more effective responses to their needs/challenges. As much as possible, objectives should reflect an
increase in functioning and ability, along with the attainment of new skills, rather that merely a decrease in
symptoms or attending appointments.
Objectives should generally satisfy all of these criteria:
1. Measurable
2. Appropriate to the treatment setting
3. Achievable
4. Understandable
5. Time-specific (don’t make this related to the duration of the ITP, work with the client for reasonable time
frames).
6. Written in action-oriented and behavioral language
7. Responsive to the individual’s unique needs, challenges, and recovery goals
8. Appropriate to the age, development, and culture of the individual and family
Goals should be appropriate to where the client is in his/her life. Here are some stages of change that may help you
and the client contemplate where they are and what they want to change.
Stages of Change:
Stage I: Pre-Contemplation
Denial
Unwillingness to change
Unaware of having a disease, disorder, disability or deficit
Unaware of the causes and consequences of the disease, disorder, disability, or deficit
Unaware of the need for treatment and rehabilitation
Lack of motivation to engage in treatment and rehabilitation
Stage II: Contemplation
Aware of their issues (problems)
Know the need for change
Not yet committed to change
Stage III: Preparation
Ready to change
Need to set goals and priorities for future change
Receptive to treatment plans that include specific focus of interventions, objectives, and intervention plans
Stage IV: Action
Makes successful efforts to change
Develop and implement strategies to overcome barriers
Requires considerable self-effort
Noticeable behavioral change takes place
Target behaviors are under self-control, ranging from one day to six months
Stage V: Maintenance
Meet discharge criteria
Be discharged
Maintain wellness and enhance functional status with minimum professional involvement
Live in environment of choice
Be empowered and hopeful
Engage in self-determination through appropriate choice-making
Stage VI: Evaluation
Assess personal outcomes
Obtain social validation and feedback from significant others
Interventions
The stage of change that the person is in helps to define the interventions that will be necessary to define and meet
the objectives.
Interventions are the activities and services provided by the members of the team-including professional and/or
peer providers, the individual and family themselves, or perhaps other sources of support within the communitythat help the individual achieve their goals and objectives. Interventions may be synonymous with treatment, care,
services, therapy, support, medications, programs, and so on. They are different from objectives, but are closely
linked. While an objective describes desired changes in status, abilities, skill, or behavior for the individual, the
interventions detail the various steps taken by the team to help bring about the changes described in the objective.
Examples:
Strengths: Supportive parents/grandparents
Abilities: “Like Sports””Like Music” “I like to fish with my Dad”
Preferences: after school appointments
Needs: “I need to stay out of trouble”
Goal: I want to feel better by not getting in trouble all the time.
Possible Objectives/Interventions:
John will be able to tell people how he is feeling without aggressive (yelling, hitting) behaviors as evidenced by
no more than 3 time outs in one week in the next 3 months. Clinician will teach anger management skills such as
‘Count to ten,”Deep breathing, etc.
John will learn how to be respectful in his communication with adults and peers in 3 out of 5 situations through the
use of play therapy and role play as evidenced by parent/teacher reports.
John will have no ISS or OSS incidents in the next 3 months as evidenced by the decrease of aggressive incidents
in the school setting as reported by his school/parents.
John’s parents will learn the use of consistent discipline and how to encourage John to express his feelings in an
appropriate manner through the use of family therapy so that John can decrease the incident of time-outs and
school incidents to less than 2 times/month as reported by the family/John/teachers.
CM will help John identify one sports program he may be interested in so that John will find one community after
school program in sports to participate in the next 3 months to increase his sense of value through teamwork..
CM will teach John and his parents or grandparents about reward system for good behaviors and they will plan at
least one activity per month based on John’s good behavior (no ISS or OSS).
Q-Tips for POC Development
First, the clinician assists the client elicit relevant treatment goals. If the client is unable to state his/her own goals,
then a family member or the clinician should establish the treatment goals.
Second, the clinician will work with the client to develop the objectives to reach the client goal(s).
Keep in mind: “The objectives are the expected observable behaviors”.
Third, the clinician works with the client to establish the measures of the objectives, as these should be based on
what the client believes h/she can do. The clinician helps the client make the measure realistic to foster success.
Fourth, the clinician includes the interventions to be used in assisting the client reach the objectives, that is, to
perform the expected behavior.
Keep in mind: Interventions are treatment methods, and activities, e.g. role-playing, supportive
interventions, education, cognitive therapy, skills development, etc.
PROGRESS SUMMARIES/REVIEWS:
¾ Done every every 90 days and at discharge.
¾ GAF/CGAS should be done with the client when present.
¾ Check off all services used during this rating period.
¾ Progress and rating on each objective. Rating scales as listed on the progress summary sheet.
1=None;2=Limited; 3=Some; 4=Significant; 5=Accomplished
¾ Narrative should include: Clinical justification of need for continuing treatment by clearly stating how the
services are necessary to treat the disorder or to prevent decompensation; Plan for future treatment or
discharge. Included family and client feedback.
¾ Integration into community: What community activities have you encouraged or gotten the client to
participate? How will this lessen his need for reliance on MHC?
¾ Are there any changes to the treatment plan?
¾ Review periods: Begin from the date of admission. Can be done up to 30 days in advance. Begin the next
review the day after the last one. Example
Admitted 7/15/05
Review date: 9/30/05 for 10/15/05
Next review would begin 10/1/05-date actually done
¾ Sign and date the progress Summary
POC, ADDENDUM, AND PROGRESS SUMMARY GUIDELINES
POC General Information
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Creating the Plan of Care with the client (and family member, as appropriate) is a
partnership. The client provides the information, as the clinician clarifies, reframes, and asks further
questions to reflect the client’s strengths, needs, abilities, and preferences for the POC.
The roles change over time. Increasingly, the client assumes more of the leadership role and requires less
input from the clinician to develop the POC
Clients need to “own” their treatment plans - without the “buy-in” of the client, success is unlikely.
The POC is a living, working document. As the client moves in the treatment process towards recovery,
the goals, objectives, interventions, and services should change; and the diagnoses may also change.
ITP Page 1 Instructions:
1. Admission Date: Should match admission date on CIS/face sheet.
2. Client’s name, CID# and Medicaid#: If a client does not have Medicaid, this block should be N/A. If
s/he becomes eligible for Medicaid, the number should be entered, dated (of entry) and initialed.
3. Primary Diagnosis: Enter the treating/billing diagnosis - should match the diagnosis on the PMO and
the Face Sheet in correct order. The first dx. on the face sheet is the billing dx. (example: 296.34 Major
Depressive Disorder, Recurrent, Severe with Psychotic Features).
4. Other Diagnoses: should be any other diagnosed problems which impact on treatment and which will be
addressed - include co-occurring disorders. (example: 301.83 Borderline Personality Disorder. Includes
Axis III - do not need CPT code for this).
5. Goals, Objectives, Interventions Area: Now there is space available for flexibility in the number of
goals, objectives and interventions (there should always be at least one of each). Please refer to the
prompts on p.1 of the POC for specific guidelines. Additions or changes to the POC (except additional
service or increase in frequency) made after the MHP has signed and dated the POC must be initialed and
dated. Increases in frequency of services or additional services must be initialed and dated by MD.
6. Goals: This is the overall statement of what the client, family member, caregiver, and/or referral source
would like to achieve, change, or obtain. Goals are broad, general, long-range, and relevant to treatment.
Goals need to be in the client’s own words (verbatim) - or a paraphrase of the client's statements. In
rare instances when a client/family is unable to come up with a goal, the clinician can write on the POC
“client unable to formulate goal – clinician’s goal is….”). Don’t state the problem in the client’s words –
state a goal (direction, future). Please think in positive terms. Instead of “Client won’t go into the
hospital,” use “Client will remain in the community or home.” You may list only one goal with multiple
objectives if the client’s functioning level is extremely low; however, there will usually be at least two
goals.
7. Objectives: Objectives are the steps (behaviors!) needed to be taken to meet the goal - how you tell if
the goal has been met.
Objectives need to be specific, observable behaviors that are
obtainable/achievable, and understandable to the client – limit professional jargon. Clients need to
understand what they are working for and how they will know when they have succeeded. These
objectives/behaviors must be realistic and relevant. The outcome of the objective must be measurable to
assure the objective was met – how often does the client believe he/she can do ___? (negotiate/consider
current baseline to determine what the measure will be). At least one objective (with intervention) is
required for each goal – and must be reflective of the expectations of the treatment team and of the
person’s age, development, and/or disabilities/disorders. Be specific – no percentages of time (use “4 out
of 5x,” as opposed to “90% of the time”).
8. Interventions: The method(s) to be used (HOW) to achieve a particular objective. Clinical interventions
can include specific treatment approaches, strengths or abilities of the client, or activities conducted by a
family member that will lead to the success/achievement of the objective. (e.g., cognitive behavioral
therapy, relaxation, role-playing, behavior modification, other psychotherapeutic techniques). Can have
multiple interventions per objective. But each objective must have at least one intervention and at least
one intervention per objective must be done by CMHC staff.
9. Target Dates: refer to the expected time a particular objective will be achieved. The date should not be
automatically related to the duration of the POC (which is one year) - need a target date for each objective.
10. Services: Services and corresponding frequencies apply to all goals on the first page. Must use
approved abbreviations only. Not all services are required to be on the POC. Any services added after the
physician signs the POC will need to be initialed and dated by the Dr. Services that are required only need
to be listed one time by an appropriate intervention. (Example: Objective/Intervention: Janie will put
away toys when asked the first time 3nights/wk by teaching behavior mgt. techniques to parents. Service
= Fam. Tx). Don’t put “weekly”, “monthly”, etc. – narrow it down as much as possible).
11. Frequency: Must be listed as required in Section II. Planned, specific frequencies are what you plan to
provide. You should not list more than you plan to render. Frequencies need to be as specific and narrow
as possible (instead of 12x/yr., put 1x/month; cannot put a range like 5 – 7 days/week). In the event more
time is needed, the Dr. can authorize it via the phone if not in the office (SPD). Any frequency changes
after the Dr. signs - the POC will need to be initialed and dated by the Dr.
12. Type of Staff: put the lowest level of staff who will be providing the service (STAD = non-MHP).
13. Client’s Signature/Initials and Date: The client signs/initials and dates as to whether or not he/she
accepted or declined a copy of the POC (required). If the client refuses to sign or initial, an entry must be
made to indicate the refusal. Check “offered and declined,” and then write “Client refused to sign,” date,
and initial this entry. If attempts to get a parent/guardian in to sign the treatment have not been successful,
that should be documented in the record and “unavailable to sign” can be written in the client signature
space.
14. Clinician Signature, Title, and Date: The MHP's signature and license, degree or title, and date
are also required on this first page. Must be legible.
15. Physician Signature, Title, and Date: The POC contains the signed and dated authorization of all
services and additions of new services by the Dr. The Dr. does not need to sign and date changes or
the addition of new goals and/or objectives. POC’s are to be reauthorized every 12 months - the
2nd and 3rd row of signatures can be N/A. The POC can be reviewed up to 30 days prior to its
expiration without altering the due date of the initial POC. The physician will write “effective on …….
“(Date of the initial ITP). Signature must be legible.
POC
Page 2 Instructions:
General Information: You may wish to complete the SNAPS before you and the client start developing the goals on
page one of the POC.
Relationship between the SNAPs and content of the POC:
Strengths & Abilities - can be used as part of the interventions to reach an objective.
Needs - relate to the goals and/or objectives.
Preferences - help determine how the treatment will be provided.
Strengths & Abilities are elements used by the client in the past or present to help him/her cope with
stressful situations. Tap into the client's assets and talents by asking:
*Which of your good points do you most often forget that have helped you feel better in the past?
*Who has stuck by you through the “ups and downs?”
*Who could help you while you are in treatment with us?
*What kinds of things do you do well that you can use to meet some of our objectives?
*What natural talents do you have?
1. Client Name and ID # - must be on the form.
2. Strengths: You might ask: What do you enjoy doing? What do you like to read? Do you belong to
a church group?
3. Needs: You might ask the client for further information about his/her needs:
If you did not feel as you do today because of the problem/illness, what would your life be like?
Would you be working? If so, what kind of job? How about your family? How would you relate
to them? What would you like this treatment to do for you? Of the things we have talked about
today, what gives you the most problem or causes you the most stress? What do family or friends
say concerns them about you? (Provide examples if needed: mood swings, sleep problems,
medication side effects, money management, housing, employment …).
4. Abilities: You might ask: Are you good at any sports? What do you like to make with your hands?
How are you at working on cars? Do you like to cook or sew?
5. Preferences: The client’s preferences are in regard to treatment. The following questions may
help the client to state what they prefer: If we can accommodate, would you prefer a male or female
counselor, a counselor familiar with your particular culture, spiritual beliefs, and/or race? If we can
accommodate, would having your appointments in the morning, over lunchtime, before 4 p.m.,
make it easier for you to keep?
6. Other Service Providers/Referrals: Include referrals to other service providers outside of the
MHC, as needed. This is often the case where there are co-occurring disorders. The next box is for
specific contact information.
7. Referral Source Information: complete as indicated.
8. Program: The clinical program where the client is currently receiving treatment is noted and
updated as needed.
9. POC Discharge/Transition Criteria: Continue to update the Discharge/Transition criteria as the client
moves toward recovery, and as needed. How will you and the client know when he/she will be ready to
transition to or from other services-or to terminate services? (Include family input if appropriate). If a
client has frequent episodes of decompensation, you could use this as a place to get them to identify
“signs” to head off re-hospitalization. (Example: in long term services and wants to live independently:
“Will progress to PRS program when auditory hallucinations have been in remission for 1 month.”)
Also “think RECOVERY,” as it applies to them and their optimal level of functioning.
10. Center Use: defined by individual Center
POC
Addendum General Information
The Addendum page permits more goals - or can be used when goals have been completed and more goals need
to be added. In order to justify continued treatment, many clients and their counselors will change or add goals
and objectives, services, and/or frequencies until all treatment needs are met. This also demonstrates movement
towards recovery.
Additional Addendum pages may be added as needed. Just remember to keep the goal numbers sequential.
“Dated” refers to the date of the POC the Addendum continues.
Note all three (3) signatures and dates are required at the bottom of each Addendum page.
The Dr. must initial and date all added services and/or increases in the frequency of services on the first page of
the POC AND the Addendum pages.
The Addendum page must be attached to the POC(stapled). Document “See POC of (appropriate date)” on the
bottom of the form.
•
•
•
•
•
•
•
Progress Summary General Information
Reviews/Summaries must be completed every 90 days from the Date of Admission.
There will be four (4) progress summaries for a 12-month time period.
The Progress Summary is to be placed in the chart at opening with Name, ID#, and current GAF.
At the time of the review, all objectives on the POC must be addressed/rated.
If the client has mastered a goal/objective, it should be noted with another goal/objective added, if needed.
The MHP is to review the following areas (preferably with the client): client’s progress toward the
treatment objectives and goals, the appropriateness of the services provided and their frequency, the
need for continued treatment, and recommendations for continued services.
The last 90-Day Progress Summary (at 360 days) is also the Annual Review of the Treatment Plan.
Progress Summary Instructions:
1. Client Name and ID#: must be on the form.
2. Review Period: The dates of the 90 days the review covers - corresponds to the Admission Date.
3. Current GAF and CAFAS: note and enter into CIS at the time of the rating.
4. Services: check all that were provided during the time frame.
5. Objective number: enter the number you are rating from the POC and/or POC Addendum.
6. Outcome rating: rate each objective.
7. The Progress Summary narrative: must address all the needed information as listed on
the prompts on form. If no progress, you need to justify continuing the service and/or
objective. Explain/justify any and all changes or continuing services. Ask yourself what would
happen if services were discontinued? Things like decompensation, re-hospitalization,
expulsion from school, etc. are things that are pertinent here.
*If the client transfers to another program, the progress summary should be completed up
to the transfer date. The receiving MHP will complete the 90 day summary on the due
date. Each person should sign and date his/her entry. A Center Discharge/Transfer Form
(checking Transfer) will also need to be placed in the record. The Discharge/Transfer Form
may reference the Summary Form.
*If closing the record, the last 90 day summary is to be done even if not due. The
Discharge/Transfer Form may reference the Summary Form.
8. Signature, including title, and date: the day the form is completed - on or up to 30 days
before the end of the time frame.
PLAN OF CARE
CLIENT NAME:
CLIENT ID #:
PRIMARY DIAGNOSIS ADDRESSED IN TX.: CODE AND DESCRIPTION
(changes need to be dated and initialed)
ADMISSION DATE:
PAGE 1
MEDICAID #: (if applicable)
OTHER DIAGNOSIS ADDRESSED IN TX.: CODE AND DESCRIPTION
(changes need to be dated and initialed)
PROMPTS:
Number Goals and Objectives (1., 1A, 1B; 2., 2A, 2B as appropriate)
Goals should be in the words of the client, family, and/or stakeholder - list things they would like to achieve, change, or need help with.
Objectives should be reflective of the client’s expectations, development, culture/ethnicity, tx. team’s expectations, understandable to the client & their family as
appropriate, appropriate to the DX; and behavioral, measurable, achievable.
Interventions at least one for each objective that tells how and what is done to achieve the objective.
(MD MUST INITIAL AND DATE ANY ADDED SERVICES OR CHANGES IN FREQUENCY AFTER MD SIGNATURE/AUTHORIZATION BELOW)
TARGET
DATE
COPY
CLIENT SIGNATURE AND DATE
(indicates input and copy offered)
Accepted
Declined
Accepted
Declined
Accepted
Declined
SCDMH FORM
NOV. 2004 (REV. APR. 2006) C-181
CLINICIAN SIGNATURE, TITLE AND DATE:
SERVICES
FREQUENCY
TYPE
OF STAFF
PHYSICIAN SIGNATURE, TITLE AND DATE:
(confirms medical necessity and appropriateness)
PLAN OF CARE
CLIENT NAME:
PAGE 2
CLIENT ID #:
Strengths: (programs, institutions, people in client’s life that offer support/
motivation)
Needs: (treatment or global needs, include legal involvements/requirements,
e.g., court ordered to tx.)
Abilities: (assets/skills of the client that can be used in treatment)
Preferences: (appt. times, therapist, types of treatment, language of
preference)
Other Service Providers/Referrals: (include co-occurring disabilities/needs
beyond the scope of the MHC)
VR
DDSN
DSS
A&D
DHEC
MD
OTHER (list)
Program:
Discharge/Transition Criteria: (initiated with the client on intake)
Center Use: Medical Necessity
Other: List other Diagnosis Relevant to Treatment:
SCDMH FORM
NOV. 2004 (REV. APR. 2006) C-181
Referral Source Information:
Contact Name:
Other:
Telephone:
ADDENDUM TO PLAN OF CARE
CLIENT NAME:
CLIENT ID #:
PRIMARY DIAGNOSIS ADDRESSED IN TX.: CODE AND DESCRIPTION
(changes need to be dated and initialed)
DATED:
ADMISSION DATE:
MEDICAID #: (if applicable)
OTHER DIAGNOSIS ADDRESSED IN TX.: CODE AND DESCRIPTION
(changes need to be dated and initialed)
PROMPTS:
Number Goals and Objectives (1., 1A, 1B; 2., 2A, 2B as appropriate)
Goals should be in the words of the client, family, and/or stakeholder - list things they would like to achieve, change, or need help with.
Objectives should be reflective of the client’s expectations, development, culture/ethnicity, tx. team’s expectations, understandable to the client & their family as
appropriate, appropriate to the DX; and behavioral, measurable, achievable.
Interventions at least one for each objective that tells how and what is done to achieve the objective.
(MD MUST INITIAL AND DATE ANY ADDED SERVICES OR CHANGES IN FREQUENCY AFTER MD SIGNATURE/AUTHORIZATION BELOW)
TARGET DATE
COPY
CLIENT SIGNATURE AND DATE
(indicates input and copy offered)
Accepted
Declined
Accepted
Declined
Accepted
Declined
SCDMH FORM
NOV. 2004 (REV. APR. 2006) C-181
CLINICIAN SIGNATURE, TITLE AND DATE:
SERVICES
FREQUENCY
TYPE
OF STAFF
PHYSICIAN SIGNATURE, TITLE AND DATE:
(confirms medical necessity and appropriateness)
ITP Review Period:
___/___/___ to ___/___/___
3m
6m
9m
12m
Progress Summary
Name:
Current GAF:
(Due at transfer, discharge, and no less often than every 90 days)
ID #:
Current CAFAS:
Other Rating:
Admission Date:
(Outcome Rating Scale: 1- None 2- Limited
(optional)
3- Some 4- Significant 5- Accomplished)
Check All Services Received: PMA
PMA-APRN
Med Adm
NS
CI
Assmt
SPD
Ind. Tx.
Fm. Tx.
Gp. Tx.
TCM
CCS
PRS
STAD
ACT
WRAPS-BI
WRAPS-CG
Summary: 1. Progress on each goal & tx. objective (outcome rating and narrative). 2. Clinical Justification of the need for continuing treatment by clearly
stating how the continuation of services is necessary to treat the disorder or prevent decompensation (the benefit or impact of the services) and/or criteria
for discharge to another program or from Center. 3. Plan/recommendation for future treatment, include client and family feedback; integration of client into
the community and changes in treatment planning. For transfer or discharge, list medications/efficacy.
Objective
Outcome
Number
Rating
Clinician’s Signature and Title:
Date:
Progress Summary
ITP Review Period:
___/___/___ to ___/___/___
3m
6m
9m
12m
(Due at transfer, discharge, and no less often than every 90 days)
Current GAF:
Current CAFAS:
Other Rating:
(Outcome Rating Scale: 1- None 2- Limited
(optional)
3- Some 4- Significant 5- Accomplished)
Check All Services Received: PMA
PMA-APRN
Med Adm
NS
CI
Assmt
SPD
Ind. Tx.
Fm. Tx.
Gp. Tx.
TCM
CCS
PRS STAD ACT
WRAPS-BI
WRAPS-CG
Summary: 1. Progress on each goal & tx. objective (outcome rating and narrative). 2. Clinical Justification of the need for continuing treatment by clearly
stating how the continuation of services is necessary to treat the disorder or prevent decompensation (the benefit or impact of the services) and/or criteria
for discharge to another program or from Center. 3. Plan/recommendation for future treatment, include client and family feedback; integration of client into
the community and changes in treatment planning. For transfer or discharge, list medications/efficacy.
Objective
Outcome
Number
Rating
Clinician’s Signature and Title:
Date:
Calendar for ITP, Outcomes (adult, CAFAS, GAF/CGAS), Progress Summary, & Change forms
Admit Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
Jan
Prog Sum
Annual
Review
PS
Prog Sum
Annual
Review
Mar
April
PS
Nov
Dec
Prog Sum
Annual
Review
Prog Sum
Annual
Review
PS
Prog Sum
Annual
Review
PS
Change
form/GAF
CBCL
1. PS= Progress Summary
2. Annual Review (things to do):
a.
Change form to update housing and employment/diagnosis, etc
b.
CBCL or adult outcome forms
c.
GAF/CGAS
d.
Annual Assessment
e.
Fee sheets updated
f.
Progress summary
g.
New ITP
PS
Prog Sum
Annual
Review
PS
PS
Change
form/GAF
CBCL
PS
PS
PS
PS
Change
form/GAF
CBCL
PS
PS
Change
form/GAF
CBCL
PS
Prog Sum
Annual
Review
PS
Change
form/GAF
CBCL
PS
PS
Change
form/GAF
CBCL
PS
PS
PS
Change
form/GAF
CBCL
Sept
PS
Change
form/GAF
CBCL
PS
PS
PS
Change
form/GAF
CBCL
Aug
Oct
Prog Sum
Annual
Review
PS
PS
PS
Change
form/GAF
CBCL
PS
Prog Sum
Annual
Review
June
PS
PS
Change
form/GAF
CBCL
PS
PS
May
July
PS
Prog Sum
Annual
Review
Feb
PS
PS
Change
form/GAF
CBCL
Prog Sum
Annual
Review
PS
Prog Sum
Annual
Review
SECTION 17
CRISIS MANAGEMENT FORM and SAFETY PLANS
This form is to be used by all clinical staff (regular and after hours) to document the service of crisis management.
It does not supplant the use of the Initial Clinical Assessment for routine clinical admissions. These forms are used
to help track monthly service data to report to DMH and Board of Directors.
Crisis management is defined in the Community Mental Health Services manual as an intensive, time limited
service by a MHP face to face with the consumer following or during abrupt substantial changes in function and/or
a marked increase in personal distress which results in an emergency situation for the consumer or the consumer’s
environment.
This means the consumer may come in off schedule or may present for a scheduled appointment with the above
criteria. One of these forms should be completed for ALL consumers receiving this service:
¾ For consumers with an open BCMHC medical record, complete sections of crisis management form
indicated on the attached example. On CSN reference crisis management form (e.g. “See Crisis
Management Form dated this date).
¾ For new admissions, complete entire form along with other admission paperwork, on CSN, reference crisis
management form (e.g. “See Crisis Management Form dated this date).
¾ CSN’s: “Emerg/Afhrs” and “Problem” need to reflect emergency and type of problem (e.g. psychiatric,
A/D)
¾ Original form to be placed in the Medical Record and a copy to supervisor of Access Center.
A Safety Plan should be put in place if the client has any tendency toward harmful behaviors to self or
others. This plan should be put into place as soon as possible after admission if needed. It should
address triggers toward the behaviors and preferences of the client as to how to resolve the thoughts
or behaviors. (see attached Form)
PAGE 120118
BERKELEY COMMUNITY MENTAL HEALTH CENTER
CRISIS MANAGEMENT/ BRIEF ASSESSMENT FORM
INFORMATION (SCREEN 8)
Discharge:
YES
TIME:
AM PM
CID#:
DATE:
SVC LOCATION:
Center
Hosp:
CLIENT STATUS:
New
Established
NO
SSN:
TYPE CONTACT: Phone
_____________________________________________________________________________________
Name: (Last)
(First)
(M.I.)
(Suffix)
Face to Face
_______________________________
Date of Birth
________________________________________________________________________________________________________________________
Address: (street)
(PO Box)
(City)
(Zip)
(county of residence)
Phone: Home _____________________________ Work __________________________ Cell ___________________________
SEX: M
F
RACE:
White
African/American
Spanish/American
Asian/American
American Indian
Other
Payor Source: Medicaid ____________________________ Medicare: _____________________________ Self Pay: Y
N
Champus: _______________________________________ VA _____________________________________________
(Military Sponsor’s SSAN)
(Client’s SSAN)
Private Insurance Company Name: __________________ Policy # _______________
Policy Holder: _____________________________________________ Client’s relationship to Holder: _________________________________
Referral Source: ___________ Presenting Problem: __________ Case manager ID#: __________ Location code: _______ Office Code: ___
Type of Committment: __________ Type of Papers: ___________
Living Arrangement: ________ Household composition: ___________
Is consumer living in SCDMH housing/ receiving a rent subsidy? Y
N
If yes what type: __________________________________ Competency: ( Jail inmates only) _________________
Prior Psych admissions: Inpatient _____________ Outpatient _____________ Date last seen: ______________
I or
O (check one)
GAF/CGAS ________________ DATE ________________ EMPLOYMENT STATUS: ___________ EMPLOYMENT LEVEL__________
Dates employed: ______________ Terminated: _____________ Hourly wages: _____________ Job Class: ______________
DIAGNOSIS: 1) _____________ 2) ____________ 3) ___________ 4) __________ 5) _________ v-code: __________
Adults: Answer yes or no to the following statements:
_____ Planned or attempted suicide in the past 12 months
_____ Lacked legitimate productive role
_____ Impairment in main productive roles, consistently missing work 1 full day per month
_____ Serious interpersonal impairment, socially isolated, lacking intimacy and social support
Children:
_____ Interferes with child’s role or functioning in family, school, or community
_____ Difficulties in achieving or maintaining one or more developmentally appropriate skills
_____ Impairments episodic, recurrent or continuous other than those temporary responses to stressful events in environment
_____ Met this criteria during year without benefit of treatment or support services
PROGRAM:
K = emergency stabilization
Return home
M = Community support
N = Outpatient
Y = Special projects
DISPOSITION
COMMUNITY:
Return to detention center
BCMHC Hosp Diversion
Chas Crisis Stab.
ER: Medical Clearance:
Pending bed available
Referral to Outpatient Services:
INPATIENT
Y
N Where? ________________
Admission Date: ______________
Admission Type: (circle all that apply)
Hospital admitted to (circle one):
DMH funded?
Yes
No
Voluntary
Bryan
Morris Village
Other sources used: (check one)
Chas Crisis Stab
PAGE 120
Emergency
Psych
WSPI
None
A&D
Harris
Forensic
MUSC
Judicial
Palmetto
Emerg Room Pending Bed Avail
BCMHC Hospital Diversion
Homeshare Respite
Other: ________
Discharge Client :
Y
Reason for discharge:
Completed Intervention: Y
Referral upon discharge:
N
N
CASE DISPOSITION/DISCHARGE
Discharge Date:______________________
ISCDEC
Yes
No
DISCHARGE PLAN AND SUMMARY:
Referral made: Y
N Where?
Referral accepted by client: Y
N
Referral source notified:
Y
N
Recommendations made to address client needs:
If ineligible for service give reason:
Contact recommendations if BCMHC services needed in future:
____________________________________________________________
CRISIS INTERVENTION ASSESSMENT AND PLAN
Presenting Symptoms: (check all that apply)
Alcohol abuse/dependency
Drug abuse/dependency
Suicide gesture/attempt
Other self destructive behavior
Decreased appetite
Delusions
‫ ٱ‬Confusion
Anxiety
Anger, Hostility
Impulsiveness
Depression
Violent threats/behavior
Auditory hallucinations
Memory problems
Fearfulness/paranoia
Suicidal/homicidal ideation
Difficulty sleeping
Visual Hallucinations
Disorientation
Labile emotions
Other: (list)
Presenting problem/Interventions:
Plan:
Name of physician assessing client: __________________________________________________________
________________________________________________________________________________________________________________________
Staff Name (print)
Staff Signature and Title
Date
Staff ID # ________________ Staff time in minutes: _________________
Original to: Chart
Copy to: Access Center Supervisor
PAGE 121
Administration
PERSONAL SAFETY PLAN
Client Name and ID#:
Based on available history and input from client/family, what triggers might lead to escalating behaviors or
“crisis?”
Based on available history and input from the client/family, what coping skills does the client have that can be
utilized to prevent escalating behaviors?
Are there any warning signs that might signal escalating behaviors?
Does the client have any preferred interventions for de-escalating his/her dangerous behaviors?
Has the client executed any advance directive (psychiatric or otherwise) to guide decision making?
Client Signature and Date:
Staff Signature and Date:
SECTION 18
DISCHARGE/TRANSITION PLANNING

Discharge/transition planning begins at the time of initial assessment. (What do you want help with? How
can we help? How will you know when you are ready to leave treatment?)

The POC formulation process also speaks to Discharge/transition criteria. (How will the consumer feel,
behave, and recognize change?)

During the treatment process and treatment reviews, discharge options should be considered. CSN’s should
contain discussions regarding discharge/transition.
Example: John has accomplished his goal of decreasing depressive symptoms, he is sleeping, has gone
back to work, his relationship with his wife has improved. He continues to have need of resolving his issues
with his parents. We discussed his needs and I informed him of several treatment options; a monthly
medication monitoring group to address his need to follow on medication along with individual counseling.
When he feels his need for counseling is done we will transition him to case management services. John is
in full agreement with this plan.

Discharge/transition Form should wrap up a summary of treatment, SNAP’s and why the
discharge/transition is taking place. The consumer should be involved in all phases of this planning.

If the consumer is transitioned to other services, the receiving case manager will follow up to assure needs
are being met. If the consumer leaves all service the standard discharge follow up will occur.
For a record to be considered closed, the paperwork described below must be completed:
1.
CLIENT DISCHARGE FORM-SCDMH FORM PDR-2
Used only if client is discharged from the Center.
2.
REFERRAL/DISCHARGE/TRANSITION FORM
3.
PROGRESS SUMMARY/REVIEW to close out treatment from time of previous review to the time of
closure.
CLOSING CHARTS WITH OUTSTANDING PRESCRIPTIONS:
Unless the client dies, a chart cannot be closed while the client has outstanding prescriptions. If a client moves, etc.
and there is documentation that the physician and supervisor approved the discharge with an outstanding
prescription the chart may be closed.
Clients who have been assessed emergently or after-hours not appropriate for treatment: Not known to Center:
-Crisis Management Form
Every block must be completed with appropriate information
A narrative must be included in the MHP Case Notes indicating disposition of the client and whether our
intervention is complete or not. If no further care is indicated by our Center-complete the discharge summary
portion of the form. The front desk will close the chart by the indicated space on the form.
Clients who have been assessed Routinely and are found not appropriate for Outpatient Treatment:
-Initial Clinical Assessment Form-See form for case disposition information
-PDR-2
PAGE 122
BERKELEY COMMUNITY
MENTAL HEALTH CENTER
Discharge Summary or Transition Plan
This form is being used to (check one):
Client Name:
Discharge from MHC services
CID#:
Date of Admission:
Transfer to another program
Date of Discharge/Transition:
Reason for Discharge/Transition:
Diagnosis at Admission:
Diagnosis at Discharge/Transition:
GAF at Admission:
Strengths:
GAF at Discharge/Transition:
Abilities:
Needs:
Preferences:
Current Medications (list medications, dosages):
Will the client be discharged/transferred on medication?
Yes
No
Explain.
Presenting Condition/Problem(s)/Symptom(s):
What services were provided and what were the results of services/progress on recovery at the time of discharge/transition
(Include the following: Were goals/objectives met? Gains achieved? Progress in his/her recovery?):
Date of Last Contact:
Client Status at Last Contact:
Recommendations for Follow-up/Support (include information about referrals to other agencies):
1). If symptoms re-appear you may return to the mental health center for further evaluation and treatment.
2). Referred to
.
Contact name & phone number:
Person participating in Discharge Summary/Transition Plan:
Staff Signature/Title/Date:
Client received a copy of the Discharge Summary/Transition Plan:
PAGE 13
Yes
No
SCDMH FORM
APR. 99 (REV. AUG 2009) (F.M. 09 10 09) C-52
Discharge/Transition Form Instructions:
1. Client Name: Give client full name as indicated on the record.
2. CID#: List the CID# listed on the record.
3. Date of Admission: See date on the face sheet.
4. Date of Action: The actual date you are closing/transitioning client
5. Diagnosis: List dx on the ITP.
6. Strengths: List strengths that client has acquired during tx or what client gave in the beginning of tx.
7. Needs: See above
8. Abilities: See above
9. Preferences: List what client prefers at this point in their tx.
10. Presenting problems/symptoms: List the problems/symptoms that the client came to us with.
11. Current problems/symptoms: Include the client’s progress/lack of progress in resolving these
problems/symptoms. Give a detailed summary of your treatment or your efforts to get the client involved in
treatment
12. Date of staffing with supervisor: List appropriate date you staffed this client for closure. If a doctor was
involved include this.
13. Reasons for transfer/discharge: Include statements such as – Unable to engage client in treatment- Client has
met his goals of …………. and now wishes to be on medication management- Client moved to Timbuktu and
wishes to pursue his tx there-Unable to locate client have attempted phone calls, home visits, etc.
14. Medications: If the client was on medication, please list the most recent meds prescribed and how they
responded to the meds
Will the client be discharged on meds?: This is where you answer no or that they have moved and have a Rx
for the interim period.
15. Internal Referral: Check the appropriate box
16. External Referral: Give the name of the referral and appropriate information concerning the referral
17. Services provided during tx: This is a list of services provided since admission
18. To what extent were goals and objectives achieved?: List to the best of your ability how the client has done
in treatment. They either made minimal progress, no progress or whatever, please don’t say “Unknown, client
dropped out” You have some idea of where they were when last seen. Give that information and then say there
has been no contact since……. And say what you have tried to do to make that contact.
19. Were the consumer/family’s expectation for tx met?: This is from your d/c criteria on the ITP. Did they do
what they said or expected to do.
20. Recommendations for service or community support: What will it take to keep them stable in the
community? What agencies or support systems should they have? How do family help with this?
21. Persons involved with the plan: List all those who helped with this plan. If you know the client is moving or
will be transferring to med mgmt you can do the plan ahead of time with the client’s input.
22. Consumer aware…: Check the appropriate block.
23. Copy offered: Check the appropriate block. A copy can be mailed to the client if he/she is not present.
24. Have the consumer sign if present.
25. Clinician signature and date
PAGE 124
SECTION 19
TREATMENT SUMMARY LETTERS & DISABILITY DETERMINATION REQUESTS
Before any information can be released about a consumer several things must happen:
1.
A properly signed release for that information must be in the Section II of the chart. (See Section 11.
Release of Information , for requirements).
2.
A Miscellaneous note must be placed in Section IV of the chart stating exactly what information you sent
and to whom.
3.
If you send a summary letter, you must retain a copy in Section II of the chart and reference that copy on
the Misc note documenting the disclosure.
The form for preparing a treatment summary letter can be found on the Center intranet site.
Vocation Rehabilitation Disability Letters and other valid requests for treatment records:
7.
46.
47.
48.
49.
All requests from DDD will be processed through the medical records department to include:
a.
being logged
b.
stamped with date of receipt
c.
checking the release for records to be an original
d.
with the client or authorized person’s signature
e.
witnessed
f.
a date of birth
g.
Social Security #
h.
Dates of services requested
The medical records department designated staff will copy the medical record for the requestor in
accordance with the Policy Number 03-005 of the CSS manual. The case manager and supervisor must sign
approval for the records to be sent to the entity requesting the records.
Medical records staff will log in the date they mail/deliver the copied records to the requestor after
receiving the approval to release from the case manager and supervisor.
The request will be monitored and followed up be Medical records staff to insure the processing and
forwarding of these records in a timely manner. Supervisors are involved as needed to speed up the
processing of these records.
A bill is assessed for copying of records. The agency does provide other treatment providers and DDD
copies without charge.
PAGE 125
SECTION 21
DIAGNOSTIC CODING
Diagnoses are listed by number for those listed in the CIS system. Another list of DSM only diagnoses
are listed in apha order. Please remember that DSM diagnosis may not be listed in the CIS list. CIS is
a cross between DSM and ICD-9. These are the numbers that must be used in our system.
PAGE 135
CIS DIAGNOSIS CODES
Run Date: 3/5/2010
Run by: BRN86
pdsm
pdsm_descr
290.0
SENILE DEMENTIA, UNCOMPLICATED-ONSET, PRIMARY DEGE
290.12
PRESENILE DEMENTIA WITH DELUSIONS-ONSET PRIM. DEGE
290.40
VASCULAR DEMENTIA, UNCOMPLICATED
290.42
VASCULAR DEMENTIA, WITH DELUSIONS
290.43
VASCULAR DEMENTIA, WITH DEPRESSED MOOD
291.0
ALCOHOL INTOXICATION DELIRIUM
291.2
ALCOHOL-INDUCED PERSISTING DEMENTIA
291.3
ALCOHOL-INDUCED INDUCED PSYCHOTIC DISORDER, WITH H
291.5
ALCOHOL-INDUCED PSYCHOTIC DISORDER, WITH DELUSIONS
291.89
ALCOHOL-INDUCED ANXIETY DISORDER (NEW CODE AS OF 1
291.9
ALCOHOL-RELATED DISORDER NOS
292.0
AMPHETAMINE WITHDRAWAL
292.11
AMPHETAMINE-INDUCED PSYCHOTIC DISORDER, WITH DELUS
292.12
AMPHETAMINE-INDUCED PSYCHOTIC DISORDER, WITH HALLU
292.81
AMPHETAMINE INTOXICATION DELIRIUM
292.84
AMPHETAMINE-INDUCED MOOD DISORDER
292.89
AMPHETAMINE-INDUCED ANXIETY DISORDER
292.9
AMPHETAMINE-RELATED DISORDER NOS
293.81
PSYCHOTIC DISORDER DUE TO...[INDICATE THE GENERAL
293.82
PSYCHOTIC DISORDER DUE TO...[INDICATE THE GENERAL
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 1 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm
pdsm_descr
293.83
MOOD DISORDER DUE TO...[INDICATE THE GENERAL MEDIC
293.84
ANXIETY DISORDER DUE TO... (NEW CODE AS OF 10/01/9
293.89
CATATONIC DISORDER DUE TO...[INDICATE THE GENERAL
293.9
MENTAL DISORDER NOS DUE TO...[INDICATE THE GENERAL
294.0
AMNESTIC DISORDER DUE TO...[INDICATE THE GENERAL M
294.10
DEMENTIA DUE TO...[INDICATE THE GENERAL MEDICAL CO
294.11
DEMENTIA DUE TO...[INDICATE THE GENERAL MEDICAL CO
294.8
AMNESTIC DISORDER NOS
294.9
COGNITIVE DISORDER NOS
295.00
SIMPL SCHIZOPHREN-UNSPEC
295.10
SCHIZOPHRENIA, DISORGANIZED TYPE
295.20
SCHIZOPHRENIA, CATATONIC TYPE
295.30
SCHIZOPHRENIA, PARANOID TYPE
295.32
PARANOID SCHIZO-CHRONIC
295.35
PARANOID SCHIZO-REMISS
295.40
SCHIZOPHRENIFORM DISORDER
295.60
SCHIZOPHRENIA, RESIDUAL TYPE
295.70
SCHIZOAFFECTIVE DISORDER
295.90
SCHIZOPHRENIA, UNDIFFERENTIATED TYPE
295.92
SCHIZOPHRENIA NOS-CHR
295.95
SCHIZOPHRENIA NOS-REMISS
296.00
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIF
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 2 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm_descr
pdsm
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MILD
296.01
296.02
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MODERATE
296.03
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE W
296.04
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE W
296.05
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN PARTI
296.06
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN FULL
296.20
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECI
296.21
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MILD
296.22
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MODERAT
296.23
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, SEVERE
296.24
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, SEVERE
296.25
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN PART
296.26
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL
296.27
MAJOR DEPRESSION, SEVERE, WITH PSYCHOTIC BEHAVIOR
296.3
MJR DEPRESS-RECUR EPISOD
296.30
MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED
296.31
MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD
296.32
MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE
296.33
MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITHO
296.34
MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH
296.35
MAJOR DEPRESSIVE DISORDER, RECURRENT, IN PARTIAL R
296.36
MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMI
296.4
BIPOLAR AFFECTIVE, MANIC
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 3 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm
pdsm_descr
296.40
BIPOLAR I DISORDER, MOST RECENT EPISODE HYPOMANIC
296.41
BIPOLAR I DISORDER, MOST RECENT EPISODE MANIC, MIL
296.42
BIPOLAR I DISORDER, MOST RECENT EPISODE MANIC, MOD
296.43
BIPOLAR I DISORDER, MOST RECENT EPISODE MANIC, SEV
296.44
BIPOLAR I DISORDER, MOST RECENT EPISODE MANIC, SEV
296.45
BIPOLAR I DISORDER, MOST RECENT EPISODE MANIC, IN
296.46
BIPOLAR I DISORDER, MOST RECENT EPISODE MANIC, IN
296.50
BIPOLAR I DISORDER, MOST RECENT EPISODE DEPRESSED,
296.51
BIPOLAR I DISORDER, MOST RECENT EPISODE DEPRESSED,
296.52
BIPOLAR I DISORDER, MOST RECENT EPISODE DEPRESSED,
296.53
BIPOLAR I DISORDER, MOST RECENT EPISODE DEPRESSED,
296.54
BIPOLAR I DISORDER, MOST RECENT EPISODE DEPRESSED,
296.55
BIPOLAR I DISORDER, MOST RECENT EPISODE DEPRESSED,
296.56
BIPOLAR I DISORDER, MOST RECENT EPISODE DEPRESSED,
296.60
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED, UNS
296.61
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED, MIL
296.62
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED, MOD
296.63
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED, SEV
296.64
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED, SEV
296.65
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED, IN
296.66
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED, IN
296.7
BIPOLAR I DISORDER, MOST RECENT EPISODE UNSPECIFIE
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 4 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm_descr
pdsm
BIPOLAR DISORDER NOS
296.80
296.89
BIPOLAR II DISORDER
296.90
MOOD DISORDER NOS
297.1
DELUSIONAL DISORDER
297.3
SHARED PSYCHOTIC DISORDER
298.8
BRIEF PSYCHOTIC DISORDER
298.9
PSYCHOTIC DISORDER NOS
299.00
AUTISTIC DISORDER
299.80
ASPERGER'S DISORDER
300.00
ANXIETY DISORDER NOS
300.01
PANIC DISORDER WITHOUT AGORAPHOBIA
300.02
GENERALIZED ANXIETY DISORDER
300.11
CONVERSION DISORDER
300.14
DISSOCIATIVE IDENTITY DISORDER
300.15
DISSOCIATIVE DISORDER NOS
300.21
PANIC DISORDER WITH AGORAPHOBIA
300.22
AGORAPHOBIA WITHOUT HISTORY OF PANIC DISORDER
300.23
SOCIAL PHOBIA
300.29
SPECIFIC PHOBIA
300.3
OBSESSIVE-COMPULSIVE DISORDER
300.4
DYSTHYMIC DISORDER
300.6
DEPERSONALIZATION DISORDER
300.7
BODY DYSMORPHIC DISORDER
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 5 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm
pdsm_descr
300.81
SOMATIZATION DISORDER
300.82
SOMATOFORM DISORDER NOS (NEW CODE AS OF 10/01/96)
300.9
UNSPECIFIED MENTAL DISORDER (NONPSYCHOTIC)
301.0
PARANOID PERSONALITY DISORDER
301.13
CYCLOTHYMIC DISORDER
301.20
SCHIZOID PERSONALITY DISORDER
301.22
SCHIZOTYPAL PERSONALITY DISORDER
301.4
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
301.50
HISTRIONIC PERSONALITY DISORDER
301.6
DEPENDENT PERSONALITY DISORDER
301.60
DEPENDENT PERSONALITY DISORDER
301.7
ANTISOCIAL PERSONALITY DISORDER
301.81
NARCISSISTIC PERSONALITY DISORDER
301.82
AVOIDANT PERSONALITY DISORDER
301.83
BORDERLINE PERSONALITY DISORDER
301.9
PERSONALITY DISORDER NOS
302.2
PEDOPHILIA
302.4
EXHIBITIONISM
302.6
GENDER IDENTITY DISORDER IN CHILDREN
302.70
SEXUAL DYSFUNCTION NOS
302.85
GENDER IDENTITY DISORDER IN ADOLESCENTS OR ADULTS
302.9
PARAPHILIA NOS
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 6 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm_descr
pdsm
ALCOHOL INTOXICATION
303.00
303.90
ALCOHOL DEPENDENCE
304.00
OPIOID DEPENDENCE
304.10
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC DEPENDENCE
304.20
COCAINE DEPENDENCE
304.30
CANNABIS DEPENDENCE
304.40
AMPHETAMINE DEPENDENCE
304.80
POLYSUBSTANCE DEPENDENCE
304.90
OTHER (OR UNKNOWN) SUBSTANCE DEPENDENCE
305.00
ALCOHOL ABUSE
305.1
NICOTINE DEPENDENCE
305.10
NICOTINE DEPENDENCE
305.20
CANNABIS ABUSE
305.40
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC ABUSE
305.50
OPIOID ABUSE
305.60
COCAINE ABUSE
305.70
AMPHETAMINE ABUSE
305.90
CAFFEINE INTOXICATION
307.1
ANOREXIA NERVOSA
307.21
TRANSIENT TIC DISORDER
307.22
CHRONIC MOTOR OR VOCAL TIC DISORDER
307.23
TOURETTE'S DISORDER
307.3
STEREOTYPIC MOVEMENT DISORDER
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 7 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm
pdsm_descr
307.42
INSOMNIA RELATED TO...[INDICATE THE AXIS I OR AXIS
307.46
SLEEP TERROR DISORDER
307.47
DYSSOMNIA NOS
307.50
EATING DISORDER NOS
307.51
BULIMIA NERVOSA
307.52
PICA
307.6
ENURESIS (NOT DUE TO A GENERAL MEDICAL CONDITION)
307.7
ENCOPRESIS, WITHOUT CONSTIPATION AND OVERFLOW INCO
307.80
PAIN DISORDER ASSOCIATED WITH PSYCHOLOGICAL FACTOR
307.89
PAIN DISORDER ASSOCIATED WITH BOTH PSYCHOLOGICAL F
307.9
COMMUNICATION DISORDER NOS
308.3
ACUTE STRESS DISORDER
309.0
ADJUSTMENT DISORDER WITH DEPRESSED MOOD
309.21
SEPARATION ANXIETY DISORDER
309.24
ADJUSTMENT DISORDER WITH ANXIETY
309.28
ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESS
309.3
ADJUSTMENT DISORDER WITH DISTURBANCE OF CONDUCT
309.4
ADJUSTMENT DISORDER WITH MIXED DISTURBANCE OF EMOT
309.81
POSTTRAUMATIC STRESS DISORDER
309.9
ADJUSTMENT DISORDER UNSPECIFIED
310.1
PERSONALITY CHANGE DUE TO...[INDICATE THE GENERAL
311
DEPRESSIVE DISORDER NOS
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 8 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
311.
pdsm_descr
pdsm
Depressive Disorder NOS
312.30
IMPULSE-CONTROL DISORDER NOS
312.31
PATHOLOGICAL GAMBLING
312.32
KLEPTOMANIA
312.33
PYROMANIA
312.34
INTERMITTENT EXPLOSIVE DISORDER
312.39
TRICHOTILLOMANIA
312.81
CONDUCT DISORDER CHILDHOOD-ONSET TYPE (NEW CODE AS
312.82
CONDUCT DISORDER ADOLESCENT-ONSET TYPE (NEW CODE A
312.89
CONDUCT DISORDER UNSPECIFIED ONSET (NEW CODE AS OF
312.9
DISRUPTIVE BEHAVIOR DISORDER NOS
313.23
SELECTIVE MUTISM
313.81
OPPOSITIONAL DEFIANT DISORDER
313.82
IDENTITY PROBLEM
313.89
REACTIVE ATTACHMENT DISORDER OF INFANCY OR EARLY C
313.9
DISORDER OF INFANCY, CHILDHOOD, OR ADOLESCENCE NOS
314.00
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER, PREDOMIN
314.01
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER, COMBINED
314.9
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER NOS
315.00
READING DISORDER
315.2
DISORDER OF WRITTEN EXPRESSION
315.31
EXPRESSIVE LANGUAGE DISORDER
315.39
PHONOLOGICAL DISORDER
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 9 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm
pdsm_descr
315.9
LEARNING DISORDER NOS
317
MILD MENTAL RETARDATION
317.
MILD MENTAL RETARDATION
318.0
MODERATE MENTAL RETARDATION
318.1
SEVERE MENTAL RETARDATION
318.2
PROFOUND MENTAL RETARDATION
319
MENTAL RETARDATION, SEVERITY UNSPECIFIED
319.
UNSPECIFIED MENTAL RETARDATION
327.01
SLEEP DISORDER DUE TO...[INDICATE THE GENERAL MEDI
333.82
NEUROLEPTIC-INDUCED TARDIVE DYSKINESIA
333.90
MEDICATION-INDUCED MOVEMENT DISORDER NOS
347.
NARCOLEPSY
625.8
FEMALE HYPOACTIVE SEXUAL DESIRE DISORDER DUE TO...
780.09
DELIRIUM NOS
780.9
AGE-RELATED COGNITIVE DECLINE
799.9
DIAGNOSIS DEFERRED ON AXIS II
799.90
995.2
ADVERSE EFFECTS OF MEDICATION NOS
995.50
CHILD ABUSE UNSPEC.
995.51
CHILD EMOTIONAL/PSYCHOLOGICAL ABUSE
995.52
NEGLECT OF CHILD (IF FOCUS OF ATTENTION IS ON VICT
995.53
SEXUAL ABUSE OF CHILD (IF FOCUS OF ATTENTION IS ON
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 10 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
pdsm_descr
pdsm
PHYSICAL ABUSE OF CHILD (IF FOCUS OF ATTENTION IS
995.54
995.59
OTHER CHILD ABUSE AND NEGLECT
995.81
PHYSICAL ABUSE OF ADULT (IF FOCUS OF ATTENTION IS
995.83
SEXUAL ABUSE OF ADULT (IF FOCUS OF ATTENTION IS ON
V15.81
NONCOMPLIANCE WITH TREATMENT
V61.10
PARTNER RELATIONAL PROBLEM (NEW CODE AS OF 10/01/9
V61.12
PHYSICAL ABUSE OF ADULT (IF BY PARTNER) (NEW CODE
V61.20
PARENT-CHILD RELATIONAL PROBLEM
V61.21
NEGLECT OF CHILD
V61.8
SIBLING RELATIONAL PROBLEM
V62.2
OCCUPATIONAL PROBLEM
V62.3
ACADEMIC PROBLEM
V62.81
RELATIONAL PROBLEM NOS
V62.82
BEREAVEMENT
V62.89
BORDERLINE INTELLECTUAL FUNCTIONING
V65.2
MALINGERING
V71.02
CHILD OR ADOLESCENT ANTISOCIAL BEHAVIOR
V71.09
NO DIAGNOSIS ON AXIS II
Created: 1/29/2004
Modified: 3/5/2010
Author: DMD
File Name: K:\IQobject\Crystal Files\BN-diagnosis in CIS.rpt
Page 11 of 11
Record Selection Criteria:
{_clients.adminact} = "N" and
IsNull ({_clients.dischrgdat})
DSM-IV Diagnoses and Codes
Alphabetical
316
[ Specified Psychological Factor ] Affecting [Indicate the General
Medical Condition ]
V62.3
Academic Problem
V62.4
Acculturation Problem
308.3
Acute Stress Disorder
309.9
Adjustment Disorder Unspecified
309.24 Adjustment Disorder With Anxiety
309
Adjustment Disorder With Depressed Mood
309.3
Adjustment Disorder With Disturbance of Conduct
309.28 Adjustment Disorder With Mixed Anxiety and Depressed Mood
309.4
Adjustment Disorder With Mixed Disturbance of Emotions and
Conduct
V71.01 Adult Antisocial Behavior
995.2
Adverse Effects of Medication NOS
780.9
Age-Related Cognitive Decline
300.22 Agoraphobia Without History of Panic Disorder
305
Alcohol Abuse
303.9
Alcohol Dependence
303
Alcohol Intoxication
291
Alcohol Intoxication Delirium
291.81 Alcohol Withdrawal
291
Alcohol Withdrawal Delirium
291.89 Alcohol-Induced Anxiety Disorder
291.89 Alcohol-Induced Mood Disorder
291.1
Alcohol-Induced Persisting Amnestic Disorder
291.2
Alcohol-Induced Persisting Dementia
291.5
Alcohol-Induced Psychotic Disorder, With Delusions
291.3
Alcohol-Induced Psychotic Disorder, With Hallucinations
291.89 Alcohol-Induced Sexual Dysfunction
291.89 Alcohol-Induced Sleep Disorder
291.9
Alcohol-Related Disorder NOS
294
Amnestic Disorder Due to...[Indicate the General Medical
Condition]
294.8
Amnestic Disorder NOS
305.7
Amphetamine Abuse
304.4
Amphetamine Dependence
292.89 Amphetamine Intoxication
292.81 Amphetamine Intoxication Delirium
292
Amphetamine Withdrawal
292.89 Amphetamine-Induced Anxiety Disorder
292.84 Amphetamine-Induced Mood Disorder
292.11 Amphetamine-Induced Psychotic Disorder, With Delusions
292.12 Amphetamine-Induced Psychotic Disorder, With Hallucinations
292.89 Amphetamine-Induced Sexual Dysfunction
292.89 Amphetamine-Induced Sleep Disorder
292.9
Amphetamine-Related Disorder NOS
307.1
Anorexia Nervosa
301.7
Antisocial Personality Disorder
293.84
Anxiety Disorder Due to...[Indicate the General Medical
Condition]
300
Anxiety Disorder NOS
299.8
Asperger's Disorder
314.9
Attention-Deficit/Hyperactivity Disorder NOS
314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type
314.01
Attention-Deficit/Hyperactivity Disorder, Predominantly
Hyperactive-Impulsive Type
314
Attention-Deficit/Hyperactivity Disorder, Predominantly
Inattentive Type
299
Autistic Disorder
301.82 Avoidant Personality Disorder
V62.82 Bereavement
296.8
Bipolar Disorder NOS
296.56
Bipolar I Disorder, Most Recent Episode Depressed, In Full
Remission
296.55
Bipolar I Disorder, Most Recent Episode Depressed, In Partial
Remission
296.51 Bipolar I Disorder, Most Recent Episode Depressed, Mild
296.52 Bipolar I Disorder, Most Recent Episode Depressed, Moderate
296.54
Bipolar I Disorder, Most Recent Episode Depressed, Severe With
Psychotic Features
296.53
Bipolar I Disorder, Most Recent Episode Depressed, Severe
Without Psychotic Features
296.5
Bipolar I Disorder, Most Recent Episode Depressed, Unspecified
296.4
Bipolar I Disorder, Most Recent Episode Hypomanic
296.46 Bipolar I Disorder, Most Recent Episode Manic, In Full Remission
296.45
Bipolar I Disorder, Most Recent Episode Manic, In Partial
Remission
296.41 Bipolar I Disorder, Most Recent Episode Manic, Mild
296.42 Bipolar I Disorder, Most Recent Episode Manic, Moderate
296.44
Bipolar I Disorder, Most Recent Episode Manic, Severe With
Psychotic Features
296.43
Bipolar I Disorder, Most Recent Episode Manic, Severe Without
Psychotic Features
296.4
Bipolar I Disorder, Most Recent Episode Manic, Unspecified
296.66 Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission
296.65
Bipolar I Disorder, Most Recent Episode Mixed, In Partial
Remission
296.61 Bipolar I Disorder, Most Recent Episode Mixed, Mild
296.62 Bipolar I Disorder, Most Recent Episode Mixed, Moderate
296.64
Bipolar I Disorder, Most Recent Episode Mixed, Severe With
Psychotic Features
296.63
Bipolar I Disorder, Most Recent Episode Mixed, Severe Without
Psychotic Features
296.6
Bipolar I Disorder, Most Recent Episode Mixed, Unspecified
296.7
Bipolar I Disorder, Most Recent Episode Unspecified
296.06 Bipolar I Disorder, Single Manic Episode, In Full Remission
296.05 Bipolar I Disorder, Single Manic Episode, In Partial Remission
296.01 Bipolar I Disorder, Single Manic Episode, Mild
296.02 Bipolar I Disorder, Single Manic Episode, Moderate
296.04
Bipolar I Disorder, Single Manic Episode, Severe With Psychotic
Features
296.03
Bipolar I Disorder, Single Manic Episode, Severe Without
Psychotic Features
296
Bipolar I Disorder, Single Manic Episode, Unspecified
296.89 Bipolar II Disorder
300.7
Body Dysmorphic Disorder
V62.89 Borderline Intellectual Functioning
301.83 Borderline Personality Disorder
780.59 Breathing-Related Sleep Disorder
298.8
Brief Psychotic Disorder
307.51 Bulimia Nervosa
305.9
Caffeine Intoxication
292.89 Caffeine-Induced Anxiety Disorder
292.89 Caffeine-Induced Sleep Disorder
292.9
Caffeine-Related Disorder NOS
305.2
Cannabis Abuse
304.3
Cannabis Dependence
292.89 Cannabis Intoxication
292.81 Cannabis Intoxication Delirium
292.89 Cannabis-Induced Anxiety Disorder
292.11 Cannabis-Induced Psychotic Disorder, With Delusions
292.12 Cannabis-Induced Psychotic Disorder, With Hallucinations
292.9
Cannabis-Related Disorder NOS
293.89
Catatonic Disorder Due to...[Indicate the General Medical
Condition]
V71.02 Child or Adolescent Antisocial Behavior
299.1
Childhood Disintegrative Disorder
307.22 Chronic Motor or Vocal Tic Disorder
307.45 Circadian Rhythm Sleep Disorder
305.6
Cocaine Abuse
304.2
Cocaine Dependence
292.89 Cocaine Intoxication
292.81 Cocaine Intoxication Delirium
292
Cocaine Withdrawal
292.89 Cocaine-Induced Anxiety Disorder
292.84 Cocaine-Induced Mood Disorder
292.11 Cocaine-Induced Psychotic Disorder, With Delusions
292.12 Cocaine-Induced Psychotic Disorder, With Hallucinations
292.89 Cocaine-Induced Sexual Dysfunction
292.89 Cocaine-Induced Sleep Disorder
292.9
Cocaine-Related Disorder NOS
294.9
Cognitive Disorder NOS
307.9
Communication Disorder NOS
312.82 Conduct Disorder, Adolescent Onset Type
312.81 Conduct Disorder, Childhood Onset Type
300.11 Conversion Disorder
301.13 Cyclothymic Disorder
293
Delirium Due to...[Indicate the General Medical Condition]
780.09 Delirium NOS
297.1
Delusional Disorder
290.1
Dementia Due to Creutzfeldt-Jakob Disease
294.1
Dementia Due to Head Trauma
294.1
Dementia Due to HIV Disease
294.1
Dementia Due to Huntington's Disease
294.1
Dementia Due to Parkinson's Disease
290.1
Dementia Due to Pick's Disease
294.1
Dementia Due to...[Indicate the General Medical Condition]
294.8
Dementia NOS
290.1
Dementia of the Alzheimer's Type, With Early Onset,
Uncomplicated
290.11
Dementia of the Alzheimer's Type, With Early Onset, With
Delirium
290.12
Dementia of the Alzheimer's Type, With Early Onset, With
Delusions
290.13
Dementia of the Alzheimer's Type, With Early Onset, With
Depressed Mood
290
Dementia of the Alzheimer's Type, With Late Onset,
Uncomplicated
290.3
Dementia of the Alzheimer's Type, With Late Onset, With
Delirium
290.2
Dementia of the Alzheimer's Type, With Late Onset, With
Delusions
290.21
Dementia of the Alzheimer's Type, With Late Onset, With
Depressed Mood
301.6
Dependent Personality Disorder
300.6
Depersonalization Disorder
311
Depressive Disorder NOS
315.4
Developmental Coordination Disorder
799.9
Diagnosis Deferred on Axis II
799.9
Diagnosis or Condition Deferred on Axis I
313.9
Disorder of Infancy, Childhood, or Adolescence NOS
315.2
Disorder of Written Expression
312.9
Disruptive Behavior Disorder NOS
300.12 Dissociative Amnesia
300.15 Dissociative Disorder NOS
300.13 Dissociative Fugue
300.14 Dissociative Identity Disorder
302.76 Dyspareunia (Not Due to a General Medical Condition)
307.47 Dyssomnia NOS
300.4
Dysthymic Disorder
307.5
Eating Disorder NOS
787.6
Encopresis, With Constipation and Overflow Incontinence
307.7
Encopresis, Without Constipation and Overflow Incontinence
307.6
Enuresis (Not Due to a General Medical Condition)
302.4
Exhibitionism
315.31 Expressive Language Disorder
300.19 Factitious Disorder NOS
300.19
Factitious Disorder With Combined Psychological and Physical
Signs and Symptoms
300.19
Factitious Disorder With Predominantly Physical Signs and
Symptoms
300.16
Factitious Disorder With Predominantly Psychological Signs and
Symptoms
307.59 Feeding Disorder of Infancy or Early Childhood
625
Female Dyspareunia Due to...[Indicate the General Medical
Condition]
625.8
Female Hypoactive Sexual Desire Disorder Due to...[Indicate the
General Medical Condition]
302.73 Female Orgasmic Disorder
302.72 Female Sexual Arousal Disorder
302.81 Fetishism
302.89 Frotteurism
302.85 Gender Identity Disorder in Adolescents or Adults
302.6
Gender Identity Disorder in Children
302.6
Gender Identity Disorder NOS
300.02 Generalized Anxiety Disorder
305.3
Hallucinogen Abuse
304.5
Hallucinogen Dependence
292.89 Hallucinogen Intoxication
292.81 Hallucinogen Intoxication Delirium
292.89 Hallucinogen Persisting Perception Disorder
292.89 Hallucinogen-Induced Anxiety Disorder
292.84 Hallucinogen-Induced Mood Disorder
292.11 Hallucinogen-Induced Psychotic Disorder, With Delusions
292.12 Hallucinogen-Induced Psychotic Disorder, With Hallucinations
292.9
Hallucinogen-Related Disorder NOS
301.5
Histrionic Personality Disorder
307.44 Hypersomnia Related to...[Indicate the Axis I or Axis II Disorder]
302.71 Hypoactive Sexual Desire Disorder
300.7
Hypochondriasis
313.82 Identity Problem
312.3
Impulse-Control Disorder NOS
305.9
Inhalant Abuse
304.6
Inhalant Dependence
292.89 Inhalant Intoxication
292.81 Inhalant Intoxication Delirium
292.89 Inhalant-Induced Anxiety Disorder
292.84 Inhalant-Induced Mood Disorder
292.82 Inhalant-Induced Persisting Dementia
292.11 Inhalant-Induced Psychotic Disorder, With Delusions
292.12 Inhalant-Induced Psychotic Disorder, With Hallucinations
292.9
Inhalant-Related Disorder NOS
307.42 Insomnia Related to...[Indicate the Axis I or Axis II Disorder]
312.34 Intermittent Explosive Disorder
312.32 Kleptomania
315.9
Learning Disorder NOS
296.36 Major Depressive Disorder, Recurrent, In Full Remission
296.35 Major Depressive Disorder, Recurrent, In Partial Remission
296.31 Major Depressive Disorder, Recurrent, Mild
296.32 Major Depressive Disorder, Recurrent, Moderate
296.34
Major Depressive Disorder, Recurrent, Severe With Psychotic
Features
296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic
Features
296.3
Major Depressive Disorder, Recurrent, Unspecified
296.26 Major Depressive Disorder, Single Episode, In Full Remission
296.25 Major Depressive Disorder, Single Episode, In Partial Remission
296.21 Major Depressive Disorder, Single Episode, Mild
296.22 Major Depressive Disorder, Single Episode, Moderate
296.24
Major Depressive Disorder, Single Episode, Severe With Psychotic
Features
296.23
Major Depressive Disorder, Single Episode, Severe Without
Psychotic Features
296.2
Major Depressive Disorder, Single Episode, Unspecified
608.89
Male Dyspareunia Due to...[Indicate the General Medical
Condition]
302.72 Male Erectile Disorder
607.84
Male Erectile Disorder Due to...[Indicate the General Medical
Condition]
608.89
Male Hypoactive Sexual Desire Disorder Due to...[Indicate the
Medical Condition]
302.74 Male Orgasmic Disorder
V65.2
Malingering
315.1
Mathematics Disorder
333.9
Medication-Induced Movement Disorder NOS
333.1
Medication-Induced Postural Tremor
293.9
Mental Disorder NOS Due to...[Indicate the General Medical
Condition]
319
Mental Retardation, Severity Unspecified
317
Mild Mental Retardation
315.32 Mixed Receptive-Expressive Language Disorder
318
Moderate Mental Retardation
293.83 Mood Disorder Due to...[Indicate the General Medical Condition]
296.9
Mood Disorder NOS
301.81 Narcissistic Personality Disorder
347
Narcolepsy
V61.21 Neglect of Child
995.52 Neglect of Child (if focus of attention is on victim)
333.92 Neuroleptic Malignant Syndrome
333.99 Neuroleptic-Induced Acute Akathisia
333.7
Neuroleptic-Induced Acute Dystonia
332.1
Neuroleptic-Induced Parkinsonism
333.82 Neuroleptic-Induced Tardive Dyskinesia
305.1
Nicotine Dependence
292
Nicotine Withdrawal
292.9
Nicotine-Related Disorder NOS
307.47 Nightmare Disorder
V71.09 No Diagnosis on Axis II
V71.09 No Diagnosis or Condition on Axis I
V15.81 Noncompliance With Treatment
300.3
Obsessive-Compulsive Disorder
301.4
Obsessive-Compulsive Personality Disorder
V62.2
Occupational Problem
305.5
Opioid Abuse
304
Opioid Dependence
292.89 Opioid Intoxication
292.81 Opioid Intoxication Delirium
292
Opioid Withdrawal
292.84 Opioid-Induced Mood Disorder
292.11 Opioid-Induced Psychotic Disorder, With Delusions
292.12 Opioid-Induced Psychotic Disorder, With Hallucinations
292.89 Opioid-Induced Sexual Dysfunction
292.89 Opioid-Induced Sleep Disorder
292.9
Opioid-Related Disorder NOS
313.81 Oppositional Defiant Disorder
305.9
Other (or Unknown) Substance Abuse
304.9
Other (or Unknown) Substance Dependence
292.89 Other (or Unknown) Substance Intoxication
292
Other (or Unknown) Substance Withdrawal
292.89 Other (or Unknown) Substance-Induced Anxiety Disorder
292.81 Other (or Unknown) Substance-Induced Delirium
292.84 Other (or Unknown) Substance-Induced Mood Disorder
292.83
Other (or Unknown) Substance-Induced Persisting Amnestic
Disorder
292.82 Other (or Unknown) Substance-Induced Persisting Dementia
292.11
Other (or Unknown) Substance-Induced Psychotic Disorder, With
Delusions
292.12
Other (or Unknown) Substance-Induced Psychotic Disorder, With
Hallucinations
292.89 Other (or Unknown) Substance-Induced Sexual Dysfunction
292.89 Other (or Unknown) Substance-Induced Sleep Disorder
292.9
Other (or Unknown) Substance-Related Disorder NOS
312.89 Other Conduct Disorder
625.8
Other Female Sexual Dysfunction Due to...[Indicate the General
Medical Condition]
608.89
Other Male Sexual Dysfunction Due to...[Indicate the General
Medical Condition]
307.89
Pain Disorder Associated With Both Psychological Factors and a
General Medical Condition
307.8
Pain Disorder Associated With Psychological Factors
300.21 Panic Disorder With Agoraphobia
300.01 Panic Disorder Without Agoraphobia
301
Paranoid Personality Disorder
302.9
Paraphilia NOS
307.47 Parasomnia NOS
V61.20 Parent-Child Relational Problem
V61.10 Partner Relational Problem
312.31 Pathological Gambling
302.2
Pedophilia
310.1
Personality Change Due to...[Indicate the General Medical
Condition]
301.9
Personality Disorder NOS
299.8
Pervasive Developmental Disorder NOS
V62.89 Phase of Life Problem
305.9
Phencyclidine Abuse
304.60 Phencyclidine Dependence
292.89 Phencyclidine Intoxication
292.81 Phencyclidine Intoxication Delirium
292.89 Phencyclidine-Induced Anxiety Disorder
292.84 Phencyclidine-Induced Mood Disorder
292.11 Phencyclidine-Induced Psychotic Disorder, With Delusions
292.12 Phencyclidine-Induced Psychotic Disorder, With Hallucinations
292.9
Phencyclidine-Related Disorder NOS
315.39 Phonological Disorder
V62.83 Physical Abuse of Adult (if by person other than partner)
V61.12 Physical Abuse of Adult (if by partner)
995.81 Physical Abuse of Adult (if focus of attention is on victim)
V61.21 Physical Abuse of Child
995.54 Physical Abuse of Child (if focus of attention is on victim)
307.52 Pica
304.8
Polysubstance Dependence
309.81 Posttraumatic Stress Disorder
302.75 Premature Ejaculation
307.44 Primary Hypersomnia
307.42 Primary Insomnia
318.2
Profound Mental Retardation
293.81
Psychotic Disorder Due to...[Indicate the General Medical
Condition], With Delusions
293.82 Psychotic Disorder Due to...[Indicate the General Medical
Condition], With Hallucinations
298.9
Psychotic Disorder NOS
312.33 Pyromania
313.89 Reactive Attachment Disorder of Infancy or Early Childhood
315
Reading Disorder
V62.81 Relational Problem NOS
V61.9
Relational Problem Related to a Mental Disorder or General
Medical Condition
V62.89 Religious or Spiritual Problem
299.8
Rett's Disorder
307.53 Rumination Disorder
295.7
Schizoaffective Disorder
301.2
Schizoid Personality Disorder
295.2
Schizophrenia, Catatonic Type
295.1
Schizophrenia, Disorganized Type
295.3
Schizophrenia, Paranoid Type
295.6
Schizophrenia, Residual Type
295.9
Schizophrenia, Undifferentiated Type
295.4
Schizophreniform Disorder
301.22 Schizotypal Personality Disorder
305.4
Sedative, Hypnotic, or Anxiolytic Abuse
304.1
Sedative, Hypnotic, or Anxiolytic Dependence
292.89 Sedative, Hypnotic, or Anxiolytic Intoxication
292.81 Sedative, Hypnotic, or Anxiolytic Intoxication Delirium
292
Sedative, Hypnotic, or Anxiolytic Withdrawal
292.81 Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium
292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder
292.84 Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder
292.83
Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic
Disorder
292.82 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia
292.11
Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder,
With Delusions
292.12
Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder,
With Hallucinations
292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual Dysfunction
292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sleep Disorder
292.9
Sedative-, Hypnotic-, or Anxiolytic-Related Disorder NOS
313.23 Selective Mutism
309.21 Separation Anxiety Disorder
318.1
Severe Mental Retardation
V61.12 Sexual Abuse of Adult (if by partner)
V62.83 Sexual Abuse of Adult (if by person other than partner)
995.81 Sexual Abuse of Adult (if focus of attention is on victim)
V61.21 Sexual Abuse of Child
995.53 Sexual Abuse of Child (if focus of attention is on victim)
302.79 Sexual Aversion Disorder
302.9
Sexual Disorder NOS
302.7
Sexual Dysfunction NOS
302.83 Sexual Masochism
302.84 Sexual Sadism
297.3
Shared Psychotic Disorder
V61.8
Sibling Relational Problem
780.52
Sleep Disorder Due to...[Indicate the General Medical Condition],
Insomnia Type
780.54
Sleep Disorder Due to...[Indicate the General Medical Condition],
Hypersomnia Type
780.59
Sleep Disorder Due to...[Indicate the General Medical Condition],
Mixed Type
780.59
Sleep Disorder Due to...[Indicate the General Medical Condition],
Parasomnia Type
307.46 Sleep Terror Disorder
307.46 Sleepwalking Disorder
300.23 Social Phobia
300.81 Somatization Disorder
300.82 Somatoform Disorder NOS
300.29 Specific Phobia
307.3
Stereotypic Movement Disorder
307
Stuttering
307.2
Tic Disorder NOS
307.23 Tourette's Disorder
307.21 Transient Tic Disorder
302.3
Transvestic Fetishism
312.39 Trichotillomania
300.82 Undifferentiated Somatoform Disorder
300.9
Unspecified Mental Disorder (nonpsychotic)
306.51 Vaginismus (Not Due to a General Medical Condition)
290.4
Vascular Dementia, Uncomplicated
290.41 Vascular Dementia, With Delirium
290.42 Vascular Dementia, With Delusions
290.43 Vascular Dementia, With Depressed Mood
302.82 Voyeurism
SECTION 22
AUDITING FORMATS FOR DMH QUARTERLY AUDITS
In order to monitor compliance with Quality Assurance requirements for medical record
documentation for all case managers and supervisors, the Quality Assurance staff will provide
consistent feedback to clinicians about the completeness and quality of documentation and
treatment in the medical record. Audit results will also provide information on clinicians’ job
performance in meeting quality assurance requirements and will be integrated into the annual
EPMS process.
Feedback to Clinicians:
Review findings will be forwarded to clinicians and supervisors for reviews and corrective
actions when indicated. QA provides summary to clinicians, supervisors, and Executive Team on
a regular basis.
Integration with EPMS process:
Audit findings and information will be maintained for each case manager. This information is
available to supervisors at the time of the case manager’s EPMS.
Copies of audit form are on the following pages.
PAGE 162
Office of Quality Management Auditors’ Manual 9Quality Assurance and Compliance January 2010 This Manual is only for the use of the employees of the Community Mental Health Centers of the SC Department of Mental Health. The copying or redistribution of parts or entirety of this Manual outside the Community Mental Health Centers is prohibited. Table of Content
Instructions
p. 4 PART 1.QUALITY ASSURANCE AND COMPLIANCE Administrative Review
Client Information and Authorizations
p. 7
Plan of Care
p. 10
Clinical Service Notes
p. 13
Medical Standards
p. 14
Medical Records
P, 16
Clinical Review Clinical Assessment
p. 18
Plan of Care p. 19
Clinical Service Note
p. 23
Treatment Process
p. 25
Utilization Review
p. 27
Medical Standards
p. 30
Discharge/Transition Plan
p. 32
PART II. COMPLIANCE STANDARDS
Organizational Structure and Responsibilities p. 34 Education and Training p. 35 Standards and Procedures p. 36 Auditing and Monitoring p. 40 Reporting and Response p. 42 Enforcement p. 43 Qualified Providers. Appendix A p. 44 Resident’s Practices. Appendix B p. 45 List of Disallowed Charges. Appendix C p. 46 Federal and State Regulations for the Administrative Review. Appendix D p. 47 Federal, State and Accreditation Regulations and Standards for the Clinical Review. Appendix E p. Instructions The Manual consists of two parts. Part I refers to Quality Assurance and Compliance reviews pertaining to the delivery of services, and Part II refers to Compliance practices conducted by the Community Mental Health Center in concordance with the DMH Compliance Plan. Part I: Quality Assurance and Compliance ‐ The Manual includes the following areas to promote the reliability of the auditors when conducting these reviews as follows: 1.
Standards: These are the requirements of state, federal, and accrediting agencies that must be observed in delivering services to ensure compliance. Some standards indisputably require reimbursement to the payor source. These are written in bold type for easier identification. These standards directly reflect federal regulations intended to control fraud and /or abuse. 2.
References: These include the specific federal, state or accreditation regulations to assist the auditor gaining information about the particular requirement, e.g. CARF, DHHS (Section 2 of the CMH Provider Manual and Discrepancy Key), False Claims Act, CMS, and DMH Compliance Standards. Under “References” are also included any specific notations or recommendations made to the auditors to enhance their ability for proper rating. 3.
Rating: M – Meets = 2 points, PM ‐ Partially Meets = 1 point, NM ‐ Not Meets = 0 points, and NA = Not applicable. Each of ratings also includes qualifying criteria to ensure reliability. 4.
Appendix: Includes copies of documents to support the state, federal and accreditation requirements. NOTE: Prior to becoming a peer auditor or a regular member of the Center QA audit team, the staff member should thoroughly review and discuss this document with the Center’s QA Coordinator to ensure understanding and proper application of the rating criteria. Part II: Compliance Practices – The intent of this Manual is to promote providers adherence to the DMH Compliance Plan in conformance with federal and state regulations and, consequently, minimize risks of fraud and abuse of federal programs. 1. Standards: These are based on the Office of the Inspector General (OIG) guidelines for the development and implementation of effective Compliance programs and are included in the DMH Compliance Plan. The standards on Auditing and Monitoring require audits of services related to the ratio, concurrence of services billed on the same day, intensity of the services provided and providers’ qualifications. Findings in these areas would indisputably yield to disallowances, or reimbursements to third party payors as appropriate. 2.
Scoring Criteria: Yes – Practice is implemented or met; Some – standard practice can be found on occasions, but not consistently; No‐ Practice is not implemented or not met; CE – Cannot Evaluate and NA – Not Applicable. 3.
Appendix – Includes relevant information to add clarification to some of the standards. Compliance Officers are encouraged to use this Manual to be thoroughly aware of the SC DMH expectations regarding the implementation of its Compliance Program and to prepare for the DMH Review, ensuring availability of all required and necessary documents. Centers are also encouraged to use this guide to conduct voluntary Compliance self‐audits in an effort to raise the awareness of Compliance among staff and ensure conformance with federal and state regulations. ADMINISTRATIVE REVIEW 1. Client Information & Authorizations 1.1 1.2 1.3 Standard References Scoring Criteria The Client Identification Sheet or Compliance Standards – 1e, and 1f. M – All four aspects are updated as indicated. Overview/Face Sheet tab in the EMR is complete, updated PM – Anyone of these aspects is either missing or not updated. Notes In the EMR look at the “Imports” and “History” tabs if the annually, and as needed. information is not in the “Overview” screen. NM – No aspects are present. Information on GAF, Diagnosis, and Language of Preference mu be current and correct. The diagnosis from the last or more recent PMO, matches the DX in the POC and CIS Overview/Face
Sheet screen in the EMR. Financial information must be updated
annually from date of admission, thus the due date should be “
the future” from audit period. The voter registration form is Section 7 of the National Voter Registration Act requires states M – Form is complete and appropriately signed by all required parties
complete, if the client is 18 yrs offer voter registration opportunities at all offices that provid public assistance and all offices that provide state‐funde NM – Form is incomplete or missing. and older, or is there documentation showing that the programs primarily engaged in providing services to persons wi client was offered the opportuni disabilities. Each applicant for any of these services, renewal NA – Client is a child/adolescent or in jail. services, or address changes must be provided with a Voter
to register Registration Form or a Voter’s Declination Form as well assistance in completing the form and forwarding the complete
application to the appropriate state or local election official. The field in the Client M – Indicated language must be consistent with the content of the DMH DIRECTIVE NO. 839‐03 ‐ Culturally and Linguistically Identification Sheet or Overview Appropriate Services to Consumers who have Limited English chart. That is, if it says “English,” as you read the record you confirm Screen in the EMR, indicating the person can speak English well. Proficiency (LEP), or are Hard of Hearing or Deaf. "Language of Preference" is adequately filled Federal fund recipients are obligated under Title VI of the Civil NM – There is no language indicated, or the language indicated in the
Rights Act of 1964 to provide limited‐English‐proficient (LEP) form is not consistent with the content of the chart. That is, the persons with meaningful access to federally funded programs. language indicated may say “English,” but there is information in the chart leading to the client not able to speak English well. # 1.4 Standard References Scoring Criteria M: Vital documents are either in the language of preference of the client, and if not, and if the client is not English speaking, there is documentation that an interpreter was used to explain the content of
the documents to the clients. PM: Vital documents are not in the language of preference of the client and a “communicator” (a person who can speak the particular language, but who is not a certified interpreter) assisted the client in understanding the documents before signing. NM: The Vital documents are not in the client’s language of preference and there is no documentation that client was assisted in This is applicable to English speaking clients as well. understanding their content before signing. DMH DIRECTIVE NO. 772.92, “Consent to Medical Treatment, M: Form is appropriately completed, signed, and dated by the client and the witness. Electroconvulsive Therapy, and Neuroleptic Medication.” PM: Form is signed and dated by the client, but not the witness. SC Code 44‐22‐40. NM: Form is not signed and dated by the client, even if signed and CMH Services Provider Manual, Section 2, “Consent to dated by the witness. Examinations and Treatment” p. 2‐16.
NA: If client was seen in a crisis. Compliance Standard #17. M: Form is signed and dated by client. Health Insurance Portability and Accountability Act (HIPAA) of NM: Form is not signed and/or dated by the client. 1996 – Public Law 104‐191 NA: The record was opened for a crisis service. The "vital documents" are written DMH DIRECTIVE NO. 839‐03 – Culturally and Linguistically in the client's "Language of Appropriate Services to Consumers who have Limited English Preference." If not, there is a note Proficiency (LEP), or are Hard of Hearing or Deaf. Procedure: 5 ‐
in the chart indicating that “The term vital documents refer to those documents containing
language assistance was provided information that is required by law or critical for the access of to assure the client's understandin services, Notice of Privacy Practices, rights, and benefits. For of their content. example, applications, consent forms, letters and notices pertaining to the reduction, denial or termination of services or benefits and letters or notices that require a response of the beneficiary or consumer.” 1.5 The Consent for Treatment and Evaluation form is completed, signed, witnessed, and dated. 1.6 The HIPAA Notice of Privacy Practice present is completed, signed, and dated. # Standard References Scoring Criteria There is evidence that the client received orientation about the services at the onset of treatment
1.7 See 2009CARF Manual ‐ 2.B.6a and 6b, p. 106‐107. Includes: An explanation of the organization’s: a. Rights and responsibilities of the client; b. Grievance and appeal procedures; c. Ways to give input regarding – quality of care, achievement o
outcomes and satisfaction; d. Services and activities; e. Expectations; f. Hours of operation; g. Access to after‐hour services; h. Code of Ethics; i. Confidentiality Policy; j. Requirements for follow‐up; k. Financial obligations, fees and arrangements; l. Familiarization with premises; m. Use of seclusion/restrain, smoking, illicit or licit drugs, weapons; n. Identification of the Case Manager; o. Program rules‐ restrictions, events, behaviors or attitudes leading to loss of rights or privileges, means for client to regain rights or privileges; p. Advance Directives (when available) q. Purpose and process of the assessment; r. Development of the POC and client’s participation; s. Transition criteria, t. Organization’s services and activities (as applicable), i.e. consistent court appearances, therapeutic interventions such as
sanctions, interventions, incentives and administrative discharg
criteria. M: Includes all indicated areas. PM: Includes some, but not all the areas. NM: There is no evidence of orientation being provided‐ i.e. Completed and signed Consent Form. NA: Client was seen in a crisis and the record was not fully opened. 2. Plan of Care (POC) # 2.1 2.2 Standard References The POC is signed by the client and/o 10/09 Revision DHHS – Section 2 CMH Service Providers Manua
family member. If not, there is p. 18, #5 – “POC Requirements.” evidence that the client refused to sign it. Note: Clients must be asked to sign their treatment plans. This practice promotes client’s compliance as it can be inferred that the client is aware of the treatment goals and the expectations treatment. Scoring Criteria M: Current POC is signed by the client (only if client is 16 y/o and older). PM: Current POC is only signed by either a client under 16 y/o or by
the adult who needs a guardian NM: Current POC is not signed by the client and there is no justification; or, there was an explanation as to the client “not being
available” to sign the POC, yet the client continued to receive services and no attempts were made by the clinician to obtain the client's signature. NA: Current POC is not signed by the client, but there is a reasonable justification as to why the treatment plan could not be signed by client‐ e.g., client did not return to services after the treatment plan was developed or client refused to sign the plan of care. There is a POC signed and dated by 10/09 Revision DHHS – Section 2 CMH Service Providers Manu M: POC was developed within 90 days from admission. the MD/LPHA within 90 days of the p. 2‐16 and 2‐21 Physician’s Signature. client's admission. PM: POC is signed, but not dated by the MD/LPHA. SC DHHS Discrepancy Key #1a and 1b. NM: Absence of MD/LPHA signature and date. Notes: LPHAs can currently authorize WRAPS and MHS‐NOS services NA: No POC needed as there are less than 90 days from admission
the POC. # 2.3 2.4 2.5 # 2.6 Standard Medicare recipients ‐ There is a treatment plan signed and dated by the authorized provider confirming medical necessity prior to providing Medicare covered services including those "incident to." References Scoring Criteria M: A treatment plan is present before “incident to” services are rendered. In the absence of a POC Form, the treatment plan should
be included in the PMOs if the MD or APRN are the authorized Medicare covered services: 1. PMA – MD and APRN 4. Individual Therapy providers. 2. Injection Administration 5. Family Therapy 3. Nursing Services 6. Group Therapy NM: There is absence of a treatment plan in the medical record. Note: Auditors may need to request the billings sheet to veri NA: Client is not a Medicare recipient. whether any other billing has occurred prior to that of th
authorized provider. The POC is reviewed and updated at SC DHHS Discrepancy Key #1c. M: POCs have been reviewed and updated for at least the last two least annually. consecutive years. In the case of MMO, clients should have an 10/09 Revision DHHS – Section 2 CMH Service Providers Manu
annual assessment and the PMO must include a new plan of care. I
p. 20 – “POC Review” and p. 2‐21 ‐“Continued Treatment”. the PMO was written by an APRN, it must be co‐signed by the MD. 2009 CARF Manual 2C.6, p. 113. PM: POCs have been reviewed, but target dates, goals and objectives have not changed and there is little or no relationship Note: If the chart has been opened more than two years, look between the goals, objectives, and current treatment. last two years. NM: POC expired and has not been renewed, updated or reviewed.
In the case of MMO level of care, the client’s plans of care m
not show significant progress, but should clearly justify th
NA: POC is not due. continuation of services at this level of care. M: All the services added and/or increases in frequency of services
The services added to the POC and/o SC DHHS Discrepancy Key # 1e increases in the frequency of service are initialed and dated by the MD or LPHA as appropriate. If the are appropriately authorized by the DHHS – Section 2 CMH Service Providers Manual, p. 19 – “PO Center has EMR, there must be an Addendum signed and dated by MD/LPHA prior to the provision of Additions or Changes.” the MD or LPHA. 10/09 Revision DHHS – Section 2 CMH Service Providers Manua services. p. 2‐19. POC Additions or Changes ‐ Services added or PM: Some of the services added and/or increases in frequency of frequencies of services changed in an existing POC must be services are either initialed, but not dated by the MD or LPHA. signed or initialed and dated by the reviewing physician except for WRAPS and MHS‐NOS, which can be authorized by either th NM: None of the services added and/or increases in frequency of physician or a Licensed Practitioner of the Healing Arts (LPHA). services were either initialed or even included in the POC. If the Center has EMR, there is no Addendum where changes could be authorized. NA: There were no changes in services and/or frequencies. Standard Compliance Standard #31. References The services utilized in treatment are SC DHHS Discrepancy Key #1d and 1e. listed in the POC with their Scoring Criteria M: All services must include their correct frequencies – PRN, or 2 x
mo., 1 x wk, etc. appropriate frequencies. 10/09 Revision DHHS – Section 2. CMH Service Provider Manua
p. 2‐18‐ “Services Required to be Listed on the POC.” The following services must be listed in the POC to receive reimbursement: • Behavioral Health Day Treatment ‐ x per ___ • Behavioral Health Prevention Education ‐ x per ___ • Community‐Based Wraparound Services ‐ x per ___ • Comprehensive Community Support Service‐ x per __ • Crisis Intervention MHS ‐ x per ___ • Family Therapy ‐ x per ___ • Group Therapy ‐ x per ___ • Individual Therapy ‐ x per ___ • Mental Health Services NOS ‐ PRN • Peer Support Service ‐ PRN • Psychosocial Rehabilitation Services ‐ x per ___ • Skills Training and Development ‐ x per___ PM: Some, but not all the services listed in the POC include their correct frequencies. NM: None of the services has the correct frequencies. NA: POC has not been developed. 3. Clinical Service Notes # 3.1 Standard 3.2 The bill time in the service notes match the actual time billed. 3.4 Scoring Criteria There is a charge for each legitimate Compliance Standard # 2a. service rendered. Note: Services provided at the end of the quarter a
sometimes keyed in the next quarter; thus, the auditor m
need to request an updated billing sheet. There is documentation for each service billed. 3.3 References M: All services provided were billed. PM: Some services provided were not billed. NM: None of the services provided were billed, to include services given free. NA: No services were provided during the audit period. M: There is a clinical service note in the medical record for each False Claims Act – 1a, 1b, 2a and 4. service billed in the audited quarter. SC DHHS Discrepancy Key # 2b. PM: There are clinical service notes for some, but not all, of the 10/09 Revision DHHS – Section 2. CMH Service Provider Manua services billed in the audited quarter. “Availability of Clinical Documentation,” p. 2‐21 to 2‐22. NM: There are no notes for any of the services billed. 2009 CARF Manual, 1F.7b (2), p. 53. NA: There were no services billed in the audit period. SC DHHS Discrepancy Key # 3e. Compliance Standard # 1f. 10/09 Revision DHHS – Section 2. CMH Service Provider Manua
“Clinical Service Note,” p. 2‐21 to 2‐22. The dates in the service notes match 10/09 Revision DHHS – Section 2. CMH Service Provider Manua
the dates they were billed. “Clinical Service Note,” p. 2‐21 to 2‐22. 2009 CARF Manual, 1F.7b(1) Compliance Standard #1f. M: The bill time in the billing sheets and in the CSN match. PM: The bill time in some of the billing sheets and CSNs match. NM: The bill times in the billings sheet and CSNs do not match. NA: There were no services billed in the audit period. M: The date in the billing sheet and in the CSN match. PM: The dates in some of the billing sheet and CSNs match. NM: The dates in the billing sheet and CSNs do not match. NA: There were no services billed in the audit period. 4. Medical Standards # 4.1 4.2 4.3 4.4 Standard References Non‐Medicare Recipients ‐ The initia SC DHHS Discrepancy Key #2a. Psychiatric Medical Assessment was provided by a physician within 90 da 10/09 Revision DHHS – Section 2. CMH Service Provider Manua
of admission or on the first service “Psychiatric Medical Assessment” – Service Description, p. 2‐34
thereafter; or within 9 months if Note: If the chart has been opened more than two years, look School‐Based Program (services offered in the school) or MHS‐NOS o last two years. Truancy Diversion. Medicaid Recipients ‐ There is a PM 10/09 Revision DHHS – Section 2. CMH Service Provider Manua
rendered by the MD before an APR “Psychiatric Medical Assessment” – Service Description, p. 2‐34
delivers a PMA. Scoring Criteria M: Client received a Psychiatric Medical Assessment by the MD within 90 days of his/her admission, or on the first service there after, or within 9 months for MHS‐NOS and Truancy Diversion Programs. NM: Client did not receive a Psychiatric Medical Assessment within the expected time. NA: Client has not been in for any services during the audit period o
client is not a Medicaid recipient. M: There is evidence of a PMA being rendered to a Medicaid recipient, prior to the APRN bills the client. NM: The APRN delivered services prior to the MD seeing the client. NA: No PMA services have been delivered by an APRN or client is not a Medicaid recipient. MMO Level of Care ‐ There is a PM 10/09 Revision DHHS – Section 2. CMH Service Provider Manua M: There is a PMO stating the client is appropriate for this level of rendered by the MD assigning clie “Medical Management Only,” p. 2‐25‐26. care and a plan of care to be followed. to this level of care. PM: There is a PMO in stating the client is appropriate for this level
of care, but there is no clear plan of care to be followed. NM: There is no PMO stating that the client was evaluated and found to be appropriate for this level of care; or, there is a PMO, bu
makes no reference to the client being appropriate to this level of care and there is no plan of care. NA: The client is not participating in the MMO level of care. CMS (Center for Medicare & Medicaid Services) – Part B, Menta M: There is a psychiatric assessment completed by either the MD, Health Services Billing Guide, June 2009. Medicare Recipients ‐ There is an DO, Clinical Psychologist (Ph.D.), APRN, PA or LISW, prior to services
being rendered, directly by the authorized provider or incident to initial psychiatric assessment done b an authorized provider prior to the Note: Auxiliary personnel include clinicians credentialed as them with the exception of the LISW. provision of covered services. LMSWs, LPCs, LMFTs, and RNs. However, although also considered authorized providers, PAs, Clinical Psychologists, NM: Auxiliary staff delivered covered services before proper LISWs, and APRNs can also deliver services “incident to” an MD psychiatric assessment by the authorized providers. or DO. A DO is a physician with the credentials of “Doctor in Osteopathy.” A PA has the credentials of a “Physician Assistant NA: The client is not a Medicare recipient. and is not a physician, but has prescribing privileges as the APRN. 5. Medical Records # 5.1 5.2 5.3 Standard References Each page in the medical record is Compliance Standard #17. identified with the client's name and/or identification number. Scoring Criteria M: All pages in the medical record include the client’s name and or CID #. PM: Some of the pages in the medical record include the client’s name and or CID #. When required, all the clinical M: All clinical documents have legible signatures/co‐signatures; SC DHHS Discrepancy Key # 2e and 2f. documents in the medical record are include the staff’s credentials and dates. legibly signed/ co‐signed, dated by Compliance Standard #36. the clinician(s), and any other PM: Some of the clinical documents have legible signatures/co‐
appropriately credentialed staff and 10/09 Revision 2009 DHHS – Section 2. CMH Service Provider signatures, include the staff’s credentials and dates include their license and/or degree. Manual, “Legibility,” p. 2‐14. ““Original legible signature and credential (e.g., Registered Nurse) or functional title (e.g., MHP NA: The medical record does not have documentation requiring of the person rendering the service must be present in all signature of the clinical staff. clinical documentation.” 2009 CARF Manual – Records of the Person Served, 2G.2 Note: Signature should be “identifiable,” which for this item is
defined as being able to identify the provider by reading the signature or using the Center’s master signature log. Give feedback for hard to read signatures. M: All the abbreviations used in the clinical notes and documents ar
10/09 Revision DHHS – Section 2. CMH Service Provider included in the DMH approved abbreviations list. The abbreviations used in the clinica Manual, “Abbreviations and Symbols,” p. 2‐14. Community documents are included in the DMH mental health service abbreviations on the Plan of Care (POC) Center approved Abbreviations List. and/or Clinical Service Notes (CSNs) must use only the approve PM: Some of the abbreviations used in the clinical notes and abbreviation for services. Service providers shall maintain a list documents are included in the DMH approved abbreviations list. of abbreviations and symbols used in clinical documentation, which leaves no doubt as to the meaning of the NM: None of the abbreviations used in the clinical notes and documentation.” documents are included in the DMH approved abbreviations list. NA: There were no abbreviations used in the clinical documents. CLINICAL REVIEW 6. Clinical Assessment # 6.1 Standard The initial clinical assessment (ICA) by the non‐physician was thoroughly completed within 3 non‐
emergency visits. References 10‐09 Revision DHHS – Section 2. CMH Service Provider Manual, “Initial Clinical Assessment,” p. 2‐15. 2009 CARF Manual,” Quality Records Review” ‐ 2H.3b. p. 134
Scoring Criteria M: All areas in the clinical (bio‐psychosocial) assessment are completed with sufficient and relevant clinical information within three non‐emergency visits. PM: Most, but not all areas in the clinical assessment are complete
with sufficient and relevant clinical information within three non‐
emergency visits. NM: Not all areas in the clinical assessment have documented information after three non‐emergency visits. NA: If client was admitted over 2 years from the time of the audit. The primary clinical assessment provid
sufficient and appropriate clinical information to justify the diagnosis according to DSM criteria. 6.2 Compliance Standards # 1e and 2a. M: The primary clinical assessment (i.e., ICA if non‐physician, or most recent PMO or updated clinical assessment) includes all the 10/09 Revision DHHS – Section 2. CMH Service Provider needed criteria as cited in the DSM to establish and justify the Manual, “Initial Clinical Assessment,” p. 2‐15 to 2‐16; Mental
diagnosis. Health Assessment by Non‐Physician, Service Description, p. 53 to 2‐54. NM: The initial clinical assessment does not include sufficient criter
to support the listed diagnosis. That is, the symptoms listed could b
Note: To verify, check the symptoms reported in the Init
included in other conditions. Clinical Assessment (ICA) against the DSM‐IV TR and th
diagnosed listed in the ICA. 7. Plan of Care (POC) # Standard The transition or discharge plan is individualized and relevant. 7.1 References 2009 CARF Manual, 2D.3. “Transition Discharge” – p. 116. Compliance Standard #14. Note: The client alone should not establish the Discharge Pla
criteria. This is a joint effort between the therapist and the client and the therapist states the agreed upon plan. Scoring Criteria M: The Discharge/Transition Plan was established at the onset of treatment, as appropriate, and took into account all of the client’s individualized needs, including those that would support the client maintain therapeutic gains once discharged. If client is expected to continue treatment indefinitely, then the D/C‐Transition Plan shoul
include this fact and indicate the supports the client must have to remain in the current level of care (if this is what is needed) or to transition to a less restrictive level of care. PM: The Discharge/Transition Plan was established at the onset of treatment and took into account some, but not all the client’s individualized needs, e.g. may refer to the resolution of client’s symptoms but not include needed supports to help the client maintain therapeutic gains once discharged. If client is expected to continue treatment indefinitely, the Discharge/Transition Plan only
states this fact and does not indicate the supports the client must have to remain in the current level of care (if this is what is needed
or to transition to a less restrictive level of care. NM: The Discharge/Transition Plan did not refer to the client’s individualized needs ‐e.g., “client will meet all treatment goals, or client will be free of symptoms.” NA: Client was seen for less than three non‐emergency visits and neither the ICA nor POC were completed before client was discharged, or the POC has not been developed. # 7.2 7.3 Standard References Scoring Criteria M: The treatment goals are in quotations, reflecting the The treatment goals are expressed in Compliance Standard #14. client/family member or guardian’s personal verbalizations. The the client's (family member or guardian if appropriate) own words. 10/09 Revision, DHHS Section 2 Manual for CMH Service statement should be reflective of the client’s cognitive and Providers, “POC Requirements”, p.2‐17; emotional ability as evident by the clinical history. 2009 CARF Manual, “Individual Plan,” 2C.3.a (1). PM: Some, but not all the treatment goals are in quotations, but Notes: they reflect the client/family member or guardian’s personal Family member or guardian’s goals are to be included when verbalizations. The statement should be reflective of the client’s the client lacks the cognitive and/or emotional abilities to sta cognitive and emotional ability as evident by the clinical history. or conceptualize treatment goals; or, when family members o guardians are active participants in the treatment of the clien NM: The stated goals do not reflect the cognitive/emotional ability
as it is with children. When included, these should be in quote even if listed on quotations. and correctly attributed, example, “ Goal “ (Mother’s ) NA: A POC has not been developed. The therapist’s goal is acceptable when clients are unable to conceptualize the treatment goals due to cognitive and/or emotional impairments, For example, when clients are in a crisis, acutely psychotic, lacking insight, resistant to treatmen
or unable to formulate a goal. . When included, these should be in quotes and correctly attributed, example, “ Goal“ (Case
Manager’s ) The objectives are written in a way tha 2009 CARF Manual, “Individual Plan,” 2C.3b. M: The language used to write all the treatment objectives is at th
is understandable to the client based o
client’s educational level, cognitive and emotional development. his/her development and age. Notes: Take into account parent/guardian level of understanding as PM: The language used to write some, but not all the treatment well. objectives is at the client’s educational level, cognitive and emotional development. To determine educational level and cognitive and emotional development of the client, look at the educational backgroun
NM: None of the treatment objectives is written at the client’s and historical information about the client’s emotional status
educational level, cognitive and emotional development. and developmental phase. NA: A POC has not been developed. # Standard References Scoring Criteria The objectives address the client's symptoms/behaviors including those o
co‐occurring disorders as identified by the client. 7.4 7.5 7.6 # M: The objectives in the POC address all of the client’s identified Compliance Standard #14. clinical symptoms, including co‐occurring disorders that may have a
effect in the outcome of treatment if not addressed. 2009 CARF Manual, “Individual Plan,” 2C.3b. Note: If co‐occurring disorders are evident in ICA, these shou PM: Some but not all of the client’s behaviors/symptoms are be addressed on POC unless the client specifically requests addressed in the objectives. that these not be address in treatment. If this is the case then there should be documentation about this under the client’s NM: The objectives in the POC do not address all of the client’s expectations about treatment section, or in the Interpretative identified clinical symptoms that may have an effect in the outcom
Summary in the ICA. of treatment if not addressed. “Behaviors” are those problem behaviors identified in the NA: A POC has not been developed. Initial Clinical Assessment. The objectives are outcome oriente 10/09 Revision, DHHS – Section 2. CMH Service Provider M: All the objectives are measurable observable behaviors directly that is, the objectives are desire Manual, “POC Requirements,” p. 2‐1/. related to the achievement of the treatment goals. observable and measurable behavio which once mastered would lead to th 2009 CARF Manual, “Individual Plan,” 2C.3b (7). PM: Some, but not all of the objectives are measurable observable
achievement of the overall treatme behaviors directly related to the achievement of the treatment goals. goals. NM: None of the objectives are measurable observable behaviors directly related to the achievement of the treatment goals. NA: A POC has not been developed. M: The client can easily reach all of the stated objectives taking into
The objectives are achievable. 2009 CARF Manual, “Individual Plan,” 2C3b. p. 112. consideration his/her stated cognitive and emotional strengths and
abilities and cultural values. Note: Objectives should take into account the client’s strengths, limitations and cultural values. PM: The client can easily reach some of the stated objectives taking
into consideration his/her stated cognitive and emotional strengths
and abilities and cultural values. NM: The client cannot easily reach any of the stated objectives taking into consideration his/her stated cognitive and emotional strengths and abilities and cultural values. NA: A POC has not been developed. Standard References Scoring Criteria The objectives are time specific. 7.7 10/09 Revision, DHHS – Section 2. CMH Service Provider Manual, “POC Requirements,” p. 2‐18; 2009 CARF, “Individua
Plan,” 2C 3b p. 112. M: All the objectives have “specific and reasonable” target dates based on the client’s needs, strengths, and limitations. PM: Most, but not all, of the objectives have “specific and reasonable” target dates based on the client’s needs, strengths, an
limitations. NM: None of the objectives have “specific and reasonable” target dates based on the client’s needs, strengths, and limitations, or the
target date indiscriminately reflect the duration/expiration of the treatment plan. NA: A POC has not been developed. 8. Clinical Service Notes # 8.1 8.2 Standard References The clinical service notes include all of 10/09 Revision DHHS – Section 2. CMH Service Provider the following elements: Manual, “Content of Individual/Group Interventions Notes, p
a. The focus of the intervention (and 2‐24. activities, if Rehabilitative groups) that are directly related to a treatment 2009 CARF Manual, “Individual Plan,” 2C.7 p. 113 and “Qualit
goal/objective (in the treatment plan) Records Review,” 2H.3d. p. 134. b. The clinician’s interventions c. The client’s response to the Note: An “intervention” is what the clinician does in the clinician’s interventions session with the client to help the client address their d. The client’s general progress in symptoms, problems and behaviors (“focus” of treatment.) relation to treatment Compliance Standards #2a, 2c, 3, 4, & 14. e. The client’s/ clinician plan for the
next session. Scoring Criteria M: The CSN include all the elements, and the focus of the intervention/activities directly relates to an objective in the POC unless the client presents with an unexpected situation or crisis, which should then be the focus of the session. PM: The CSN include some, but not all the elements; however, the focus of the intervention/activities is present and directly relates to
an objective in the POC, unless the client presents with an unexpected situation or crisis, which should then be the focus of the
session. NM: The CSN includes some, but not all the elements and the focus
of the intervention/ activities is either not listed, or not directly related to an objective in the POC. NA: There have been no services in the audit period. M: The note provides “relevant and sufficient” information about The Service Plan Development note 10/09 Revision DHHS – Section 2. CMH Service Provider reflect the MD and MHP involvement in Manual, “MH Service Plan Development,” Service Description the involvement of both the MHP and MD in the activity. the: p. 2‐136. a.
development, staffing, review and PM: The note provides “relevant but scarce” information about the
monitoring of the POC, or Note: Both the MHP and MD need to sign the CSN in order f involvement of either or both the MHP and MD in the activity. b. review of the outcome data as it this service to be paid. (C#24.c.2) impacts Dx, Tx, discharge plans and NM: The note does not provide “relevant” information about the focus of types of services, or involvement of both the MHP and MD in the activity. c.
Confirmation of medical necessity
or NA: The service was not provided during the audit period. d. Establishment of DX, and e. Recommend treatment # 8.3 8.4 8.5 Standard References Scoring Criteria The documentation in the clinical notes Compliance Standards #1i, 2a, 3, 4, 5, and 24. M: The documentation of the CSN reflects the description of the support the services billed. service as listed in the third party payer’s manual as applicable. DHHS Discrepancy Key #2d. PM: The documentation of some of the CSNs reflects the descriptio
Note: Once the service is paid back, the correct service cou of the service as listed in the third party payer’s manual as then be billed if it is included in the POC or, if it is not require applicable. to be listed in the POC for reimbursement. NM: The documentation of the CSN does not reflect the description
of the service as listed in the third party payer’s manual as applicable. NA: There were no services provided during the audit period. The documentation in the CSNs/PMOs, Compliance Standards #1a, 1f, and 1i. M: The scope of the interventions used in the session and including referenced documents (i.e. documented in the note, absolutely support the time billed in light generic tickets and other clinical notes) DHHS Discrepancy Key # 2c. of the focus of the session and the client’s responses to the support the bill time. interventions Note: A partial, rather than total reimbursement to the third party payer may be considered, based on the auditor’s clinica PM: The scope of the interventions used in the session and experience, knowledge, and judgment about the service documented in the note, partially support the time billed in light of
the focus of the session and the client’s responses to the rendered. interventions. NM: The scope of the interventions used in the session and documented in the note, do not support the time billed in light of the focus of the session and the client’s responses to the interventions NA: There were no services rendered. There are no "non‐billable" services Compliance Standard #1g. M: All services billed are covered by the third party payer(s) billed, e.g. socialization and recreational activities without a clear SC DHHS Discrepancy Key #3g. PM: the third party payer covers some, but not all the services billed
therapeutic justification. 10/09 Revision DHHS – Section 2. CMH Service Provider NM: the third party payer covers none of the services billed. Manual, “Non‐billable Medicaid Activities,” p. 2‐29. ` NA: There were no services rendered during this audit period. 9. Treatment Process # Standard References Scoring Criteria There is evidence of follow up when th
client misses an appointment. 9.1 9.2 9.3 DMH Continuity of Care Manual – Policy #12‐02 “Communi M: There is evidence of attempts to contact clients for non‐excused
Follow‐Up.” failures to keep appointments as evidenced by generic tickets or copies of letters. Documented evidence of phone call or letter for misse appointments in audit period; the spirit of this is the intentio PM: There is evidence of some attempted contacts when client fails
to engage the client in needed treatment. to show to an appointment as evidenced by generic tickets, copies o
letters. If client comes regularly and misses a day but is there the ne appt, follow‐up is not necessary. NM: There is no evidence of attempted contacts when client fails to
show to an appointment as evidenced by generic tickets, copies of A CSN that says “Will send letter” or “Will call” is not the sam letters. as doing it. NA: There were no services rendered or unexcused cancellations o
no shows during the audit period. There is evidence of inclusion of a fami 2009 CARF Manual, “Program Structure”, 2A.9a, 9b, p. 101; 2 M: Clinical service notes reflect appropriate inclusion of the family member in the client's treatment for 12b, page 102; 2C “Individual Plan,” 1c p. 111, and 2C.8i p. member in the client’s treatment. ongoing support when clinically 114. indicated. PM: Clinical service notes reflect the inclusion of the family membe
SC DMH Continuity of Care Manual, Policy #13‐09 “Family to be “lacking in continuity” when inclusion is warranted and the family member has not refused efforts to be included. Inclusion.” NM: Clinical service notes reflect minimal clinical assessment only) o
Notes: no participation of the family member in the client’s treatment and
A family member can be the “client’s biological/natural family, significant other or someone else identified by the no attempts on the part of the clinician to include the family memb
in the treatment. client” (DMH Policy #13‐09) This is particularly relevant in the treatment of children and NA: There are documented efforts of clinicians to engage the family
but the family did not want to participate in treatment. vulnerable adults. There is evidence that treatme Compliance Standard #14. M: There is documentation of sufficient linkage or attempts to link focuses on the integration of the clie the client to relevant community resources and other needed into the community. 2009 CARF Manual, “Individual Plan,” 2C.1b, p. 111; an services to promote client’s integration, independence, managemen
2C.8d, 8e, and 8h p. 114. of their illness and natural supports. Note: This refers to integration and inclusion of the client PM: There is documentation of limited linkage of, or attempts to the local community, family as or when appropriate , natur link the client to relevant community resources and other to limited
support system and other services (2009 CARF Manual) efforts on needed services to promote client’s integration, independence, management of their illness and natural supports. NM: There is no documentation of linkage of, or attempts to link th
client to relevant community resources and other needed services t
promote client’s integration, independence, management of their illness and natural supports. NA: Client’s condition did not call for referrals or linkage to other services. The Progress Summaries conducted every 90 days since after the first 180 days from admissions past 8/1/07. 9.4 9.5 M: All Progress Summaries are completed every 90 days after the Compliance Standard # 2 and 2a. first 180 days from admission. 10/09 Revision DHHS – Section 2. CMH Service Provider PM: All but one Progress Summary was past due or completed Manual, “Progress Summaries”, p.2‐20 outside the 90 days after the first 180 days from admission. Note: Look for progress summaries for the last 12 months or since date of admission. Note: for clients admitted 8/1/07 or NM: Two or more Progress Summaries were past due or not later, first Progress Summary is not due for 180 days. Dates d completed within the expected time frame. not have to be exactly on target. They could be up to 2 week late or early = M. NA: Client was admitted within six months from the day of the aud
M: All elements of the note are included in the Summary. The Progress Summary Note include: Compliance Standard #2 and 2a. a. A review of the appropriateness of PM: The justification for continued services and some other services and their frequency; 10/09 Revision DHHS – Section 2. CMH Service Provider elements, but not all (e.g., rating of outcomes, services offered) are
b. A review of the client’s progress on Manual, “Progress Summaries”, p.2‐20 included in the Summary. each objective and goals; Note: This standard applies to the most recent progre c. A justification for the client’s summary note. NM: The is no clear justification for continued services. and some continued treatment other elements, but not all, are included in the Summary. d. Recommendations for continued The justification for continued treatment should indicate ho services. the services are needed to treat the client and/or prevent d NA: No progress summaries needed to be completed prior or durin
compensation on a stable client. the audit period. If target dates for objectives are to be extended, th
justification and changes must be stated in the progre
summary. 10. Utilization Review # Standard References Scoring Criteria There is documentation to justify service SC DHHS/DMH Contract ‐ “Medical Necessity” and 10/09 M: The clinical documentation “undoubtedly substantiates” the as medically necessary. Revision DHHS – Section 2. CMH Service Provider Manual, client’s psychiatric needs. “Medical Necessity” p. 2‐4 – “All services are required to meet medical necessity” and should meet all the following NM: The clinical documentation “does not justify” the need for treatment as stated in the medical necessity statement. conditions: †Required to diagnose, treat, cure, or prevent an illness tha NA: No services are being provided. has been diagnosed or is reasonably suspected, to relieve 10.1 pain, improve and preserve health, or be essential to life; ...
† Not primarily provided for the convenience of the client, the client’s caretaker, or the provider.” Compliance Standards #1e, 2a. SC DHHS Discrepancy Key # 2d. 2009 CARF Manual, “Quality Records Review”, 2H.1b. The services as planned, including their 10/09 Revision DHHS – Section 2. CMH Service Provider M: The services as planned are clinically appropriate and at the frequency, are appropriate to treat the Manual, “Medical Necessity” p. 2‐4, “ ... right frequency and intensity and meet the three criteria of client based on his/her diagnosis, needs, † Consistent with the client’s symptoms, diagnosis and leve Medical Necessity. or ability to function in his/her roles and not be in excess of and strengths. the client’s needs.” PM: The services as planned are clinically appropriate, but the frequency and intensity (more or less than needed) † Consistent with generally accepted medical standards not experimental or investigational. NM: The services as planned may be clinically acceptable but not
appropriate to treat the client based on his/her diagnosis, needs, 10.2 and strengths. Compliance Standards #2c, 24, and 37. 10/09 Revision DHHS – Section 2. CMH Service Provid NA: No services are being provided. Manual, “Progress Summary”, p. 2‐20, Note: The intent of this standard is to ensure that services a
clinically appropriate. # Standard References Scoring Criteria The frequency and intensity in which M: The frequency and intensity in which all services are delivered
10/09 Revision DHHS – Section 2. CMH Service Provider are appropriate to effectively treat the client. 10.3 services are delivered are appropriate to Manual, “Medical Necessity” p. 2‐4, “ ... treat the client based on his/her diagnos † Consistent with the client’s symptoms, diagnosis and leve needs, and level of functioning. or ability to function in his/her roles and not be in excess of
the client’s needs.” † Consistent with generally accepted medical standards not experimental or investigational. † Not primarily provided for the convenience of the client, the client’s caretaker, or the provider.” Compliance Standards #2c, 24, and 37. Note: The intent of this standard is to ensure that services a
not over or underutilized. PM: The frequency and intensity in which some, but not all services are delivered are either more (overutilization) or less (underutilization) than what is considered clinically appropriate to
effectively treat the client. NM: The frequency and intensity of all the services delivered are either more (overutilization) or less (underutilization) than what i
considered clinically appropriate to effectively treat the client. NA: No services are being provided. The clinical interventions effectively treat Compliance Standa.rds #2a and 2c. relieve, or improve the client's symptoms/problems and behaviors, and 10/09 Revision DHHS – Section 2. CMH Service Provid
the case of client’s who are stable, the Manual, “Medical Necessity” p. 2‐4, “Progress Summary”, interventions preserve current functionin 2‐20, and/or prevent decompensation. Note: The intent of this standard is to ensure that services a
medically effective. 10.4 # Standard References Services are provided within the SC DHHS Discrepancy key #1e and 3a. maximum frequency authorized in the POC 10.5 There is no upcoding. 10.6 Compliance Standard #5. SC DHHS Discrepancy Key #3h. M: The documentation “undoubtedly shows” the client’s symptoms are resolving and/or the client has made expected progress toward his/her treatment goals and/or the client has actively maintained therapeutic gains because of the treatment regimen provided. PM: The documentation shows the client’s symptoms are resolvin
slower than expected and/or the client’s progress toward his/her
treatment goals has been limited, and/or the client has had some
difficulties maintaining therapeutic gains because of the treatmen
regimen being provided. This can occur when client follows up wi
medical care, but does not receive sufficient or any therapeutic services. NM: The documentation shows that client’s symptoms have not resolved and/or the client has not made any progress toward his/her treatment goals and/or therapeutic gains have been lost and there have been no documented efforts to change the treatment regimen to improve the client’s outcomes. NA: Client has not received any therapeutic services yet, or pt has
been non‐compliant or inconsistent with treatment and/or appointments not allowing formal treatment to take place. Scoring Criteria M: All services were provided within the maximum frequency listed in the POC. PM: Some services were provided more frequently than indicate
in the POC NM: All the services were provided more frequently than ordere
in the POC. NA: No services were provided during the audit period. M: All of the services billed accurately reflect their description in the payer’s manual and not a similar service with a higher rate. PM: Some, but not all services billed accurately reflect their description in the payer’s manual and not a similar service with a higher rate. NM: None of the services billed accurately reflect their descriptio
in the payer’s manual. Instead, they reflect a similar service with a
higher rate ‐ e.g. a service was billed ad GP TX, but the note read PRS. 11. Medical Services Standards # Standard References The Neuroleptic Consent Form is signe SC DMH Directive 772.92, “Consent to Medical Treatment, and dated by the client or guardian and Electroconvulsive Therapy and Neuroleptic Medication.” the prescribing authority when the SC Code 44‐22‐140. client is prescribed a Neuroleptic or atypical antipsychotic medication. 2009 CARF Manual, “Medication Prescribing, Dispensing and 11.1 Administering,” 2E.6d. p. 122. Scoring Criteria M: There is a Neuroleptic Consent Form in the record signed and dated by the client and the prescribing professional. PM: There is a Neuroleptic Consent Form in the record signed and dated by the client, but not the prescribing professional. NM: There is not a Neuroleptic Consent Form in the record of the client being prescribed an antipsychotic medication. NA: The client has not been prescribed a Neuroleptic or atypical antipsychotic medication. The presence of abnormal movements 2009 CARF Manual, “Medication Prescribing, Dispensing and M: There is documentation of the assessment of abnormal assessed and documented at the movement is evident in the clinical documentation at the initiation Administering,” 2E.5 (l). p. 122. initiation of treatment and thereafter treatment with antipsychotic and six months there after. every six months when the client is Note: Can be documented on AIMS sheet, in PMA or Nursing prescribed antipsychotic medications. services note. NM: There is documentation of the assessment of abnormal 11.2 movements either at the initiation of treatment and occasionally Look at the last 12 months or, if less than two years; look at thereafter, or not at the initiation of the treatment and occasionally
thereafter or not at all. the initiation of treatment. NA: The client has not been prescribed a Neuroleptic or atypical antipsychotic medication. The Medication Administration Notes include: a. The name of the medication administered b. The dosage given (quantity and 11.3 strength) c. The route (IM, ID, and IV) d. The injection site e. The side effects or adverse reactions
noted. 10/09 DHHS Manual, Section 2. CMH Service Provider Manua
“Injectable Medication Administration,” Service Description, p.2‐37. M: All elements of the note are present. PM: Some of the elements, but not all, are present. NA: The service was not rendered during the audit period. # Standard References The medication‐monitoring notes 10/09 DHHS Manual, Section 2. CMH Service Provider Manua
“Nursing Services,” Service Description, p. 2‐40. include: a. The name(s) of the medication(s) the client is taking; or, refers to the PMO where the medications are listed. b. The side effects or adverse reactions
experienced. c. Whether the client is refusing to, or 11.4 unable to, take medications as ordered
or, if the client is compliant in taking medications as prescribed. d. The effectiveness of the medications
in controlling symptoms. e. Any issues relating to co‐occurring substance use. Scoring Criteria M: All elements of the note are present. PM: Some of the elements, but not all, are present. NA: The service was not rendered during the audit period. 12. Discharge/Transition Plan # Standard References The discharge/transition plan include Compliance Standard #14. of the elements listed: 2009 CARF Manual, “Transition/Discharge” 2D.11, p. 118. a. Date of admission Note: This standard is only applicable to “closed” records, or
b. Services provided to when clients “formally transition” to another program. c. Presenting condition d. Extent to which established goals an
12.1 objectives were achieved e. Reasons for discharge f. Status of the person served at last contact g. Recommendations for services or supports h. Date of discharge from the program
Revised 1/10 by SCDMH Quality Management Scoring Criteria M: All elements of the note are present. PM: Some of the elements, but not all, are present. NM: There is documentation of the client being discharged, but there is no Discharge/Transition Summary. NA: Client is not discharged, COMPLIANCE PRACTICES
(In process)
SECTION 24
CREDENTIALING OF STAFF
All staff who provide clinical services are asked to complete the attached “SCDMH Privilege Review
and Concurrence” form as part of the application process to obtain clinical privileges. This
“Credentialing” process verifies professional competency to provide certain services as defined, and
according to the required credentials of the South Carolina Department of Mental Health. (See
attached)
Credentialing and privileging Procedures

SCDMH Privilege Review and Concurrence form is completed by new employee and submitted
to QA

Credentialing files are established according to attached filing format

When all required verifications of licensure, education and experience are received, credentialing
applications and supporting documentation are reviewed by the Executive Team who function as the
Credentialing Committee as outlined in the Quality Assessment and Improvement Plan. The Medical
Director, who is a member of this committee, provides medical review and direction in this process.

Following Executive Team review and authorization by Executive Director, SCDMH Privilege
Review and Concurrence applications are submitted to the SCDMH, QA division, for final approval.

Upon receipt of the SCDMH Privilege Review and Concurrence authorized by the Department of
Mental Health, individual staff members are notified of those areas awarded “clinical privileges”
to provide certain services.

All clinical privileges of each individual staff member will be reviewed on annual basis. For licensed
professional staff, this includes verification of license status with appropriate licensure authority.
S.C. Department Of Mental Health
Credentialing Requirements
MHP Privilege
The standards for qualification as Mental Health Professional (MHP) are defined:
Psychiatrist: A Doctor of Medicine or Doctor of Osteopathy who has successfully completed a recognized residency
training program in psychiatry and is licensed to practice psychiatry in South Carolina.
Psychiatric Nurse: A registered nurse who is licensed in SC and has a minimum of 1 year's experience in the mental
health field.
PAGE 196
Advanced Practice Registered Nurse: A registered nurse with a Master’s Degree and licensed in S.C. and is recognized
by the State Board of Nursing and has national certification.
Physician: A Doctor of medicine or Doctor of Osteopathy licensed to practice medicine in SC.
Social Worker: A holder of a Master's Degree in Social Work from an accredited university or college and licensed to
practice in the state of SC.
Clinical Chaplain: A holder of a Master of Divinity degree from an accredited theological seminary who has 2 years of
pastoral experience as a priest, minister, rabbi and 1 year of Clinical Pastoral Education which includes provision of
supervised clinical services.
Psychologist: A holder of a doctorate from an accredited university or college who is licensed in the state of SC in the
Clinical, School, or Counseling specialty areas.
Mental Health Counselor: A holder of a master's degree or doctorate from a program that is primarily psychological in
nature (e.g., counseling, guidance, social science equivalent) from an accredited university or college.
Mental Health Professional Master's Equivalent: A holder of a master's degree in a field that is related to bio-psychosocial treatment or treatment of the mental ill or a holder of a master's degree in a reasonable related field that is
augmented by graduate courses and experience in a closely related field. Also, those appropriate Ph.D. candidates who
have by-passes the master's degree but have enough hours to satisfy a master's requirement and are actively pursuing a
Ph.D.
Credentialing requirements for each service are listed with the individual service description as outlined in
the Section 2 document and Section 2 of the Rehabilitative Behavioral Health Services Manual and Targeted
Case Management Manual of DHHS effective 7/1/2010..
PAGE 197
Revised 7/1/2010 South Carolina Department of Mental Health Privilege Review and Concurrence Center Name: Name: Assigned Staff ID #: Professional Title: Requested Start Date: Social Security #: Category / Service Privileged by Center: Crisis Intervention Service H001 Med. Compliance‐Bachelor Level / Non‐
MHP H005 Targeted Case Management H031 MH Assessment Non Physician H002 Injectable Medication Administration H010 Case Management H032 Individual Therapy H003 Psychiatric Medical Assessment H012 Rehabilitation Psychosocial Service H056 Family Therapy H004 Psychiatric Medical Assessment‐APRN H013 Family Support H057 Group Therapy H005 MH Services Plan Development‐Non MD H017 Behavior Modification H058 Caregiver Group‐Bachelor Level / Non‐
MHP H005 Nursing Services H021 Peer Support Services H059 Professional Education: (Indicate highest level of education and training achieved, name of accredited university or college, date of completion, subject matter, South Carolina license or registration certificate, if any, etc.) If applicable: License # ___________ DEA # _____________ (M.D.) / License # ___ ______ Certificate # _________ (Non‐Physician Staff) Privilege Category Related Experience / Training: If Non‐Bachelor Non‐MHP, specify 3 years of experience in direct care of the mentally ill. / If RN, specify mental health experience If M.Div., specify C.P.E. units completed DMH Case Management curriculum completed: Yes No Date: _________________________________ I affirm, agree and/or understand that all statements on this form are true and accurate. Applicant’s Signature: _________________________________________________________ Date: ___________________ This applicant is appropriately licensed, certified, registered, experienced & qualified to perform the responsibilities of the privilege category/service indicated above. Center Director’s Signature: ___________________________________________________ Date: ___________________ For privilege concurrence, the Mental Health Center will send to DMH Office of Quality Assurance. (Optional) †This applicant meets the South Carolina Department of Mental Health’s standards of qualification for the privilege category / service indicated above. †This applicant does not meet the South Carolina Department of Mental Health’s standards of qualification for the privilege category / service indicated above. SCDMH Office of QA’s Signature: _____________________________________________ Date: ___________________ SECTION 25
OUTCOME MEASURES
CHILD Behavior Checklist):
The CBCL is a tool used by a reliable clinician to measure how impaired a youth is in day to day functioning,
secondary to behavioral, emotional, or substance use problems. It is used at intake, every 6 months thereafter, and
at discharge to assess change while in treatment. It is meant to be used as measurement outcome and an active
treatment planning tool with the youth and their families. Family members/caregivers fill out the form with help
from the clinician if needed.
ADULT OUTCOME TOOLS:
Clinicians should rate adults with the Center Outcome Survey for Adults form. This should be accomplished at
admission and every year thereafter. The form also asks for GAF scores. The GAF is required to be updated in CIS
every 6 months. Descriptions of the GAF scale may be found on the following pages.
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GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALE
Consider psychological, social and occupational functioning on a hypothetical continuum of mental health-illness.
Do not include impairment in functioning due to physical (or environmental) limitations.
Code:
(Note: Use intermediate codes when appropriate. e.g., 45, 68, 72).
100-91
Superior functioning in a wide range of activities, life’s problems never seem to get out of
hand, is sought out by others because of his or her many positive qualities. No symptoms.
90-81
Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all
areas, interested and involved in a wide range of activities, socially effective, generally
satisfied with life, no more than everyday problems or concerns (e.g., an occasional
argument with family members).
80-71
If symptoms are present, they are transient and expectable reactions to psychosocial
stressors (e.g., difficulty concentrating after family argument); no more than slight
impairment in social, occupational, or school functioning (e.g., temporarily falling behind in
school work).
70-61
Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in
social, occupational, or school functioning (e.g., occasional truancy, or theft within the
household) but generally functioning pretty well, has some meaningful interpersonal
relationships.
60-51
Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks)
OR moderate difficulty in social, occupational, or school functioning (e.g., few friends,
conflicts with peers or co-workers).
50-41
Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting)
OR any serious impairment in social, occupational, or school functioning (e.g., no friends,
unable to keep a job).
40-31
Some impairment in reality testing or communication (e.g., speech is at times illogical,
obscure or irrelevant) OR major impairment in several areas, such as work or school, family
relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family,
and is unable to work; child frequently beats up younger children, is defiant at home, and is
failing at school).
30-21
Behavior is considerably influenced by delusions or hallucinations OR serious impairment
in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately,
suicidal preoccupation) OR inability to function in all areas (e.g., stays in bed all day, no
job, home or friends).
20-11
Some danger of hurting self or others (e.g., suicide attempts without clear expectation of
death; frequently violent; manic excitement) OR occasionally fails to maintain minimal
personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely
incoherent or mute).
10-1
Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent
inability to maintain minimal personal hygiene OR serious suicidal act with clear
expectation of death
0
Inadequate information
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CHILDREN’S GLOBAL ASSESSMENT SCALE
(For children 4-16 years of age)
Rate the subject’s most impaired level of general functioning for the specified period by selecting the lowest level that describes
his or her functioning on a hypothetical continuum of health-illness. Use intermediary levels (e.g. 35, 58, 62). Rate actual
functioning regardless of treatment or prognosis. The examples of behavior provided are only illustrative and are not required for
a particular rating.
Specified Period: One Month
100-91 Superior functioning in all areas (at home, at school, and with peers.) Involved in a wide range of activities and has
many interests (e.g., has hobbies or participates in extracurricular activities or belongs to an organized group such as
Scouts, etc.); likeable, confident; “everyday” worries never get out of hand; doing well in school; no symptoms
90-81
Good functioning in all areas; secure in family, school and with peers; there may be transient difficulties and everyday
worries that occasionally get out of hand (e.g., mild anxiety associated with an important examination, occasional
“blowups” with siblings, parents, or peers).
80-71
No more than slight impairment in functioning at home, at school, or with peers; some disturbance of behavior or
emotional distress may be present in response to life stresses (e.g., parental separations, deaths, birth of a sibling), but
these are brief, and interference with functioning is transient; such children are only minimally disturbing to others and
are not considered deviant by those who know them.
70-61
Some difficulty in a single area, but generally functioning pretty well (e.g., sporadic or isolated antisocial acts, such as
occasional hooky or petty theft; consistent minor difficulties with school work, mood changes of brief duration; fears
and anxieties that do not lead to gross avoidance behavior; self-doubts); has some meaningful interpersonal
relationships; most people who do not know the child well would not consider him or her deviant, but those who do
know him/her well might express concern.
60-51
Variable functioning wit sporadic difficulties or symptoms in several but not all social areas; disturbance would be
apparent to those who encounter child in a dysfunctional setting or times, but not to those who see the child in other
settings.
50-41
Moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area,
such as might result from, for example, suicidal preoccupations and ruminations, school refusal and other forms of
anxiety, obsessive rituals, major conversion symptoms, frequent anxiety attacks, poor or inappropriate social skills,
frequent episodes of aggressive or other antisocial behavior wit some preservation of meaningful social relationships.
40-31
Major impairments in functioning in several areas and unable to function in one of these areas, i.e., disturbed at home,
at school, with peers, or in society at large; e.g., persistent aggression without clear instigation; markedly withdrawn and
isolated behavior due to either mood or thought disturbance, suicidal attempts with clear lethal intent; such children are
likely to require special schooling and/or hospitalization or withdrawal from school (but this is not a sufficient criterion
for inclusion in this category.
30/21
Unable to function in almost all areas, e.g., stays at home, inward, or in bed all day without taking part in social
activities or severe impairment in reality testing or serious impairment in communication (e.g., sometimes incoherent
and inappropriate.)
20-11
Needs considerable supervision to prevent hurting others or self (e.g., frequently violent, repeated suicide attempts) or
to maintain personal hygiene or gross impairment in all forms of communication, e.g., severe abnormalities in verbal
and gestural communication, marked social aloofness, stupor.
10-1
Needs constant supervision (24 hr. care) due to severely aggressive or self-destructive behavior or gross impairment in
reality testing, communication, cognition, affect, or personal hygiene.
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Global Assessment of Functioning scale Training
(GAF)
by
http://www.esocialworker.com/
http://www.esocialworker.com/
General Overview
Color-coded Decision Tool
Differential Assessment
GAF Model
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Global Assessment of Functioning
The GAF or Global
Assessment of Functioning
is a scale intended to
represent the continuum
of Mental Health to
Mental Illness. The score
represents the rater's
opinion of the client's
overall functioning in both
psychological and
social/occupational areas,
while excluding
impairment due to
physical or environmental
limitations.
G
A
F
91-100 No Symptoms;
Superior in all areas
81-90 Absent or minimal
symptoms; Good; just
"every day" problems
71-80 Limited or
expectable reactions; No
more than slight
impairment
Besides being used as an
indicator of level of
functioning, the
"Current" GAF gives a
baseline to gauge
functioning variation (e.g.
past 30 or 90 days) while
the "Highest GAF Past
Year" might be a goal to
work towards.
61-70 Mild symptoms;
Some difficulty but
functioning pretty well
51-60 Moderate symptoms;
Moderate difficulty
41-50 Serious symptoms;
Serious impairment
Be careful to not let the
"simplicity" of the scale
let you forget the
significance of accurately
applying it. Good
"gaffing" helps us
understand where an
individual is at, it also is
likely to be the foundation
of service authorizations
and outcome
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Psychological and
Social/Occupational subscales
(e.g. depression, psychosis,
suicidal ideation,
communication disorders;
school problems for
children, can't keep a job,
fights, poor personal
hygiene)
31-40 Some impairment in
reality testing or
communication; Major
impairment in several areas
such as work, school,
family relationships
21-30 Behavior is
considerably influenced by
delusions or hallucinations
OR serious impairment in
206
communication or
judgment; Inability to
function in almost all areas.
measurements. Consider
consultation if uncertain.
11-20 Some danger of
hurting self or others;
Occasionally fails to
maintain minimal personal
hygiene
1-10 Persistent danger of
severely hurting of self or
others; Persistent inability
to maintain minimal
personal hygiene OR
serious suicidal act with
clear expectation of death.
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207
Global Assessment of Functioning
One may find benefit in using the
colors of the "stoplight" to help
conceptualize 3 separate groupings
based on the the varying degrees of
severity of dysfunction. Most
people can associate a different
"degree of danger" to each color.
It is hoped that the color-coding
will help the rater to more
effectively conceptualize variations
in the degree of dysfunction.
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91-100
81-90
71-80
61-70
51-60
41-50
31-40
21-30
11-20
1-10
0 - Not
enough info
208
Global Assessment of Functioning
Routine
91-100
81-90
71-80
A commonly used
method for rating
dangerousness is to
define it as Routine,
Urgent or Emergent.
Routine situations may or may not need
any attention but the goal should be to
connect the subject with a resource within 7
days for guidance and reassurance as
appropriate. If there are issues, they are
short lived and effectively coped
with. Some of these individuals will be
those who would be in the urgent area if not
for treatment.
Urgent
61-70
51-60
41-50
Emergent!
31-40
21-30
11-20
1-10
0 - Not
enough info
Urgent situations show great variations of
intensity but lack the immediate threat of
injury. For new cases or episodes, the goal
should be to connect the subject with a
resource within 24-48 hours. Remember
that many people live day to day within the
GAF's Urgent range, with many never
accessing the service system. Some of
these individuals will be those who would
be in the emergent area if not for treatment.
Emergent situations are ones with
immediate threat of injury. For new cases
or episodes, the goal should be to
immediately connect the subject with
resources. For individuals who normally
function in this area, varying security and
safety controls would be the focus of
intervention.
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209
Global Assessment of Functioning
Pay especially close
attention when using
transitional scores
(40-41 & 70-71).
You are dramatically
changing immediacy
of need and response
intensity.
Can be interpreted as
the individual is
transitioning or
subject is/was
better/worse than
accurate.
Transitional scores
are highlighted with
the color of it's sister
score (40-41 & 7071), the reverse of
what might be
expected (40-41 &
70-71). This is done
to remind the rater of
the transitional nature
of the score.
Routine
91-100
81-90
71-80
91-100
Urgent
61-70
51-60
41-50
The severity begins to shift from routine to
urgent at this point.
71-80
61-70
51-60
Emergent!
31-40
21-30
11-20
1-10
0 - Not
enough info
41-50
This is the transitional point where you
decide if you have an Emergency. The
decision is especially difficult because you
must decide if the individual's functioning
is stabile enough to to allow the individual
to stay in the community or warrants
imposing safety controls, even if against
their will.
31-40
G
21-30
11-20
A
1-10
F
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81-90
210
Global Assessment of Functioning
To determine the GAF score, go
down the GREEN section of the
Psychological functioning subscale until you find the correct
number range (e.g. 71-80)
descriptor or determine that
the symptom severity is not in
that section. You would then
repeat for the YELLOW and, if
necessary, the RED sections
until you find the correct
number range for the
Psychological section.
Once you identify the number
range for the Psychological
sub-scale, go to the
corresponding number range
on the Social/Occupational subscale. If the dysfunction of the
Social/Occupational sub-scale is
within or better than the
corresponding Psychological
sub-scale number range, your
GAF score comes from the
identified Psychological subscale number range. If the
Social/Occupational sub-scale
dysfunction is worse, than you
continue down
Social/Occupational sub-scale
until you find the correct
number range. The GAF score
comes from this LOWEST
number range.
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
Psychological
(e.g. depression, psychosis, suicidal
ideation, communication disorders)
91-100 No Symptoms
81-90 Absent or minimal
symptoms
71-80 Limited or expectable
reactions
61-70 Mild symptoms
Social/Occupational
(eg. school problems,
can't keep a job, fights,
poor personal hygiene)
91-100 Superior in all
areas
81-90 Good; just
"every day" problems
71-80 No more than
slight impairment
61-70 Some difficulty
but functioning pretty
well
51-60 Moderate symptoms
51-60 Moderate
difficulty
41-50 Serious symptoms
41-50 Serious
impairment
31-40 Some impairment (in
reality testing or communication)
21-30 Behavior is considerably
influenced by delusions or
hallucinations OR serious
impairment in communication or
judgment.
31-40 Major
impairment in several
areas (such as work,
school, family
relationships)
21-30
Inability to
function in almost all areas
11-20 Some danger of hurting self
or others
11-20 Occasionally fails to
1-10 Persistent danger of severely
1-10 Persistent inability to
hurting of self or others
211
maintain minimal personal
hygiene
maintain minimal personal
hygiene OR serious
suicidal act with clear
expectation of death.
Global Assessment of Functioning
Using the ten-point
range of the LOWEST
scored sub-scale
(psychological or
social/occupational),
determine where the
individual fits in the
identified number range
(e.g. 22, 47, 59), based on
a hypothetical
comparison of all
individuals in that range.
71-80 Limited or
expectable reactions
61-70 Some difficulty but
functioning pretty well
OR
You choose the sub-scale
with the lowest number
range
(Social/Occupational in
this example). Given that
the subject is functioning
higher in the other subscale, I'd suggest using the
upper side (65-70).
61-70 Some difficulty but
functioning pretty well
?
Based on limited
information, I wouldn't
want to give it a
transitional score of 70.
Remember the
significance of
transitional scores (40-41
& 70-71). If uncertain, I
suggest using the midpoint (eg. 45). By doing
so, you retain the option
of being able to later
score significant progress
or regression in the
identified functioning
range.
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
Thusly, a score of 68
would be appropriate for a
subject whose functioning
is stabilizing or being
maintained. While a 66
would be appropriate for a
subject whose functioning
is deteriorating.
212
Global Assessment of Functioning
Additional Info
e. g. dysfunction; suicide risk;
differentiation between
Routine/Urgent/Emergent
The range from 71-100 is one
that represents "normal"
symptoms and functioning.
These individuals are actively
and effectively involved with
the world around them. If there
are issues, they are short lived
and effectively coped with.
Treatment is not called for, but
guidance and reassurance can
be helpful.
Psychological
(e.g. depression, psychosis,
suicidal ideation,
communication disorders)
91-100 No Symptoms
81-90 Absent or minimal
symptoms
71-80 Limited or
expectable reactions
The severity begins to shift
from routine to urgent at this
point.
61-70 Mild symptoms
61-70 Mild Depression;
Insomnia
51-60 Moderate Depression;
flat affect; panic attacks
41-50 Severe Depression;
suicidal ideation; severe
obsessive rituals
31-40 Occasional psychotic
symptoms; Impairment in
reality testing; Speech is
sometimes illogical, obscure or
irrelevant.
21-30 Hallucinations and
delusions influence behavior;
sometimes incoherent, acts
grossly inappropriately, suicidal
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
51-60 Moderate symptoms
41-50 Serious symptoms
This is the transitional point
where you decide if you have
an Emergency. The decision
is especially difficult because
you must decide if the
individual's functioning is
stabile enough to to allow the
individual to stay in the
community or warrants
imposing safety controls,
even if against their will.
31-40 Some impairment
(in reality testing or
communication)
21-30 Behavior is
213
preoccupation
11-20 Some danger due to
hallucinations or delusions;
Suicide attempts without clear
expectation of death; frequently
violent; manic
considerably influenced by
delusions or hallucinations
OR serious impairment in
communication or judgment.
11-20 Some danger of
hurting self or others
1-10 Persistent danger due to
1-10 Persistent danger of
hallucinations or delusions; This
individual is a persistent danger to
self/others
severely hurting of self or others
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
0 - Not
enough info
214
Global Assessment of Functioning
Suicidal
Psychological
41-50 ideation
(e.g. depression, psychosis,
suicidal ideation,
communication disorders)
31-40 Progressively more
21-30 preoccupation
91-100 No Symptoms
11-20 attempt without
expectation of death
81-90 Absent or minimal
symptoms
1-10 attempt with expectation
of death
71-80 Limited or expectable
reactions
Depression
61-70 mild
61-70 Mild symptoms
51-60 Moderate symptoms
51-60 moderate
41-50 Serious symptoms
41-50 severe
31-40 Some impairment (in
reality testing or
communication)
Psychosis
21-30 Behavior is
considerably influenced by
delusions or hallucinations OR
serious impairment in
communication or judgment.
31-40 some psychosis
21-30 behavior influenced by
delusions or hallucinations
11-20 some danger because of
delusions or hallucinations
11-20 Some danger of
hurting self or others
1-10 persistent danger because
of delusions or hallucinations
1-10 Persistent danger of
severely hurting of self or others
0 - Not
enough info
Communication
51-60 mild thought disorder;
circumstantial, tangential
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
215
41-50 none noted
31-40 moderate thought
disorder; sometimes illogical
21-30 severe thought disorder;
sometimes incoherent
11-20 complete inability to
communicate; generally
incoherent or mute
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
216
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
GAF can be a very powerful and
217
smears feces or may be
generally incoherent or
mute.
positive tool when used correctly, and can
have significant negative consequences if
used incorrectly.
1-10 completely unable to
take care of themselves.
Contact me if you have any questions,
especially about the color-coding
component of the model or if you are
interested in GAF training. The training
uses the model as a foundation, but
customizes the detail as is appropriate for
the given audience.
Suicidal act with clear
expectation of death.
Mark R. Marquez, LCSW, MSW, EdD
http://www.esocialworker.com/gafintro.htm
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218
SECTION 25
GENERAL GUIDELINES FOR DOCUMENTATION
All documentation should reflect a recovery process between you, the client and whoever else may be
involved in the client’s treatment. The therapeutic process begins with the Initial Clinical Assessment
when you are gathering information about the client’s reasons for coming into treatment and problems
and challenges he/she is facing. Information should be gathered from the client, family and any other
sources permitted by the client. Once you have this information, the next step is developing goals for the
client’s Individual Treatment Plan, which will be the client’s roadmap to treatment. It should be clear to
the client/family what needs to happen and the steps that the client will be taking toward progress in the
goals and objectives.
Clinical Service Notes:
CSNs should reflect the service given (see documentation reqirements for each service-Section 1) and
follow the F.I.R.P.P. format given below when applicable to the service:
Documentation:
• Focus of session- What problems did the client bring to this session? What issues/topics did you
discuss with the client and how do they affect his/her functioning
• Interventions of staff- What interventions did you provide to help solve or improve the situation?
• Response of client to intervention-How did the client respond to this intervention?
• Progress of client in relation to the treatment goals-How does this session relate to the overall
progress of the client goals on the ITP? Do you need to add goals/services to address the problems
• Plan for next sessions-This should be specific such as; Not able to completely process triggers for
anger, Will continue to address in next session.
This FIRPP documentation is appropriate to all interventions except, PMOs, Injectable Medication
Administration, Medication Monitoring, and MH Assessment Non-Physician.
The following are some guidelines/examples to help you with this documentation.
Focus of the session:
Anxiety
fears
depression
coping
Aggression
tenseness
no interest
confusion
Violence
frustration
failure
compulsivity
Outlets
demands
isolation
pressure
Awareness
expectations
preoccupation
impulse
Decisions
judgment
mood
stress
Blame
hostility
relationships
behaviors
Self-image
ineffectiveness
marriage
crisis
Alcohol
drugs
debts
death
Choices
awareness
rejection
helplessness
Religiosity
cooperation
self-esteem
support systems
Protection
faith
goals
symptoms
Work
plans
complaints
health
Stress
future
education
recovery
Interventions:
Counseled
Bolstered
Advised
Identified
Helped to..
consoled
assisted
avoided
instructed
confronted
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
directed
advocated
encouraged
interpreted
emphasized
219
discussed
addressed
guided
furnished
commended
Recommended
rejected
Suggested
reassured
Presented
provided
Re-directed
consented
Referred
sustained
Reframed
empathized
Helped client think through…….
Praised
Prodded
Elicited
Compared
urged
offered
upheld
shared
supported
role-played
re-assessed
allowed
structured
oriented
demonstrated
addressed issues of….
Helped client consider………
Evaluated
Set limits
Met needs by..
Used humor to..
Response of client:
Agreed
disagreed
Acknowledged
blamed
Adopted
established
Accepted
acted out
Clarified
chose to
Promised to think about
Enlightened
confused
Guarded
assertive
Argumentative
Reassured
Introspective
evaluated
listened
commented
reflected
focused
thoughtful
denied
suspicious
preoccupied
Progress in relation to goals:
Continues to….
Achieved
Having problems with:
Resolved
Change occurring
partial progress
needs to…
Improved in the areas of ……
integrated
manipulated
refused
ignored
resolved
angry
optimistic
agitated
withdrawn
Words that convey time spent:
Lengthy
After ____ minutes… Stated/Restated___ times
Reiterated
Numerous times
Eventually
At length
Several attempts
Repeatedly
Explained until understood
Finally
Discussed in great detail
Know that the medical record is a legal document, and as such here are some Dos and Don’ts.
DO know that:
Fraud- is knowingly and willfully executing, or attempting to execute, a scheme or deception to defraud
any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or
promises , any of the money or property owned by, or under the custody or control of, any health care
benefit program (SC Corporate Compliance Plan-Definitions/Acronyms).
In other words, it is an intentional deception or misrepresentation made by someone knowing that it
is false and could result in an unauthorized payment. Keep in mind the attempt itself is fraud,
regardless of whether it is successful (www.cms.gov).
Abuse- refers to an activity that may result in direct or indirect unnecessary costs to any health care
benefit program including improper payment or payment for items or services that fail to meet
professionally recognized standards of care, or defined by the program as medically unnecessary. Abuse
includes payment for items or services when there is no Legal entitlement to payment and the provider
has not knowingly and/or intentionally misrepresented facts to obtain payment (SC Corporate Compliance
Plan – Definitions/Acronyms).
H:\QA Manual\revised 3-10 qa manual forbcmhc.doc
220
That is abuse involves actions that are inconsistent with accepted , sound medical, business, or fiscal
practices. Abuse directly or indirectly results in an unnecessary cost to the program through improper
payments. The real difference between abuse and fraud is the person’s intent (www.cms.gov).
The standards of all the services listed in Section 1 of the manual and as stated in the third party payer
Manuals. You are responsible for the appropriate coding of the services you provide. Know what the
standards require and how the services are used.
Bill for the services provided and according to applicable standards
Assure that the clinical documentation is in the medical record immediately after the services are
provided. When this practice is not possible due to extraordinary circumstances, indicate in the record
how to access the documentation within the 72 hours following the service at which time the clinical
documentation must be in the medical record. You may use an interactive process to document your
service with your client at the end of the appointment.
Refund payment for services not documented, or for documentation not able to be located in the chart
within 72 hours of service.
Assure that the client’s diagnosis is justified by the symptoms and behaviors presented by the client
and/or reported by the client’s representative, friend, next of kin, parent, etc., during the clinical
assessment.
Justify medical necessity based on the symptoms, needs, and level of functioning of the client at least in
the interpretive summary and treatment reviews.
Know your clinical privileges and only provide services for which you are appropriately credentialed,
privileged, and qualified.
Date clinical notes and treatment plans the day when they are completed and signed.
Initial and date new entries when updating existing documents, i.e., initial clinical assessment forms,
treatment reviews, etc., and add an explanation for the new entry.
Always follow the required methods of correcting documentation.
Question any requests to alter or amend existing documentation to meet audit requirements of justify
payment, whether from a supervisor or another staff member.
DON’T !!
¾
¾
¾
¾
¾
Misrepresent diagnosis to justify payment.
Bill for services not provided.
Upcode or unbundled a service to bill at a higher rate.
Back date or alter or amend any documentation to justify payment
Alter or falsify certificates of medical necessity or other clinical documentation (clinical
notes, treatment reviews) to justify payments.
¾ Bill for or provide services you are not appropriately qualified and privileged to provide.
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221
SECTION 26
TARGETED CASE MANAGEMENT
(Medicaid eligible recipients)
TCM is now a stand alone program. Clients must meet eligibility under the Medicaid TCM
program manual. A TCM Plan must be formulated within 60 days of the first TCM activity. The
needs of the client must be assessed and a plan for how these needs will be addressed must be
formulated and signed by the clinician and the client. The client must agree to the program.
There must be follow up on access to service within 30 days of the referral and documented in
the chart. A TCM progress summary must be done every 180 days to determine the continued
need for service and the progress toward stated goals. The strengths, needs, abilities, and
preferences of the client must be documented along with this. See description of the TCM/CM
activities in Section 1.
See attached forms.
Targeted Case Management
7/1/2010
™ Target Populations
Psychiatrically Disabled Adults ; Seriously Disturbed Children: “At Risk” Pregnant wom en; Head and
Spinal Cord Injurie s and Related Disabilities ; Physically Handicapped Children; Sensory Im pairment;
Sickle Cell Disease; Substance Abuse; Functionally Impaired Adults
™ Criteria for Psychiatrically Disabled Adults:
Diagnosis of major mental disorder included in current edition of DSM under schizophrenia disorders,
major affective d isorders, severe personality disorder (in absence of seriou s antisocial disorder),
psychotic disorders, delusional disorders (paranoid), OR diagnosis of a m ental disorder and at least one
hospitalization.
™ Criteria for Seriously Disturbed Children:
-Age 4-21
-A diagnosable mental or behavioral disorder or diagnosis that meets the coding and definition criteria in
the current DSM (excluding substance abuse or addic tive disorders, irreversible dementias, mental
retardation, developmental disorders, and V-codes, unless they co-occur with a serious mental disorder).
AND
-A functional deficit which interf eres or lim its the child f rom achieving or m aintaining one o r more
developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skill.
™ Eligibility:
-Must reside in a community setting or be transitioning to a community setting following an institutional
stay.
-Must be a medicaid beneficiary or receiving services through a state agency
-Must be able to participate in th e planning process, or applicable, a responsible party on behalf of the
beneficiary.
-Must be able to benefit from the services
-Must be voluntary participant.
™ Definition of TCM:
Refers to activities which will assis t eligible beneficiaries in gaining ac cess to needed medical, social,
educational, and other services through the following four components:
-Assessemt
Comprehensive and periodic assessments of an individual to determine service needs including activities
that focus on needs identification, to determine the needs f or any medical, educational, social, or other
services. This would include; taking individual histor ies, identifying needs, ga thering information from
other sources such as family members, medical providers, social workers, and educators.
-Care Plan
Development and periodic revision of a SPECIFIC care plan based on infor mation collected in the
assessment.
-Referral and Linkage
Referral and related activities to help beneficiaries obtain needed services (making appointments with
those who can address identified needs). Follow up shall occur as quickly as indicated, but not to exceed
30 calendar days from the date the beneficiary is scheduled to receive the service referred by the CM
-Monitoring and Follow-up:
Must ensure that th e activities and contacts ad dressed in the Care Plan are effectively im plemented.
These activities m ay be with the provider, the benefi ciary, the caretak er, family members, or others.
Must be done as frequently as necessary, but at least one annual monitoring to help determ ine whether
the conditions for TCM continue to be appropriate.
™ TCM Contact:
-Face to face encounter (preferable)
-Telephone contact
™ Frequency of Contacts:
-Based on individual need
-At least once every 60 days
-Face to face at least every 180 days (preferably in the client’s natural environment)
™ TCM Covered activities:
1. Assisting in obtaining required educational, treatm ent, residential, m edical, social, or other support
services by accessing the service or advocating for service provision.
2. Contacting social, health, and rehab service provide rs, either by phone or face to face, in order to
promote access to and appropriate use of services or coordinating multiple providers.
3. Monitoring progress through the services and pe rforming periodic reviews and reassessments of
treatment needs.
4. When medical treatment is necessary, referrals or arrang ement for such treatment (making
appointments).
5. Arranging and monitoring the access
to prim ary healthcare providers including written
correspondence sent to a primary care provider which gives a synopsis of the treat ment the individual is
receiving.
6. Coordinating and monitoring other health care needs.
7. Staffing m eetings related to re ceiving consultation and supervision on spec ific case to f acilitate
optimal case management (moving client from on program to another or one agency to another).
8. Contacts to deal with specific and identifiable problems of the service access which requires the CM
to guide or advise in the solution of the problem.
9. Contacts with families, representatives of human service agencies, and other service providers to form
a multidisciplinary team to develop a comprehensive and individualized service plan, which describ es
problems and corresponding needs and details services to be accessed or procured to meet those needs.
10. Preparation of a written repo rt that details a psyc hiatric and/or functional st atus, history, treatment,
or progress (other than for lega l or consultative purposes) for physic ians, other service providers, or
agencies.
™ Who can provide TCM:
-Commission for the Blind
-Continuum of Care (COC)
-Department of Alcohol and other Drug Abuse Services (DAODAS)
-Department of Disabilities and Special Needs (DDSN)
-Department of Health and Environmental Control (DHEC)
-Department of Juvenile Justice (DJJ)
-Department of Mental Health (17 Community Mental Health Centers) (DMH)
-Department of Social Services/Intensive Foster Care and Clinical Services (DSS/IFCCS)
-Department of Social Services (DSS)
-Medical University of South Carolina (MUSC)
-School for the Deaf and Blind
-Sickle Cell Foundation
™ Hierarchy Guidelines:
If more than one of the above agencies is providing care for a beneficiary, only one can be designated as
the primary CM. The other agency would then be de signated to provide Concurrent Care. Exa mples of
this would be the following:
DMH/DSSIFCCS: IFCCS would be primary and DMH would be concurrent
DMH/DJJ; DMH would be primary and DJJ concurrent
MDH/COC: COC would be primary and DMH concurrent
DMH/DDSN: DDSN would be primary and DMH concurrent
DMH/ DAODAS: would depend on who is providing the most service-need to negotiate with each other
At any time, if a concurrent provi der is predominantly meeting the treatment and service needs of the
individual, or if the prim ary case m anager has failed to adequately coordinate care and services, the
concurrent CM may initiate contact with the p rimary CM at the loca l level to request a change in the
primary CM. A meeting should be set up between the two agencies to discuss the feasibility of a change
in the primary CM. This m ust be documented in the each provider’s case management record. (These
meetings are not billable to TCM.) If the situation cannot be resolved between the two agencies, it can
be referred to the state HHS for determination.
™ Concurrent Care:
Concurrent care entails notifying the primary CM concerning the identified needs of the beneficiary, not
providing the com ponents of TCM. No one should be denied the services be cause of designation of
primary and concurrent CMs.
™ Who can provide TCM:
-Psychiatrically Disabled Adults:
PhD
Or MSW
Or Masters degree in Social Work, Psychology, Counseling, or closely related field
Or BSN in above mentioned disciplines
Or RN licensed to practice in state of SC
-Seriously Emotionally Disturbed Children
Masters degree in Social Work, Psychology, Counseling, or closely related field
Or Baccalaureate degree in Social Work, Psychology, Counseling, Special Education, or closely related
field and one year of experience performing clinical or case work activities
Or Baccalaureate degree in an unrelated field or study and 3 years of experience performing clinical case
work
Or RN licensed to practice in SC with 3 years of experience performing clinical or case work activities.
™ Documentation:
Case Management Plan (CMP): must be completed (based on assess ment of needs) within 60 days of
first billed TCM activity
Beneficiaries must sign the CMP, as this service is voluntary.
Must be updated every 365 days.
Must have progress summaries every 180 days.
Additions to CMP must be dated and signed/initialed by the CM
The case manager signs and dates plan.
Activity Notes must be documented for each specific activity rendered to a beneficiary.
Must include start and stop times.
Specify component of TCM being provided
Reflect delivery of a billable service
Be signed, titled, and dated by the provider of the service
Filed in the record when delivered, no later than 5 service days
Must justify need for TCM
What process of TCM is being used: accessing, referring, arranging, or linking to service
Provide ongoing follow-up to ensure services continue to be necessary and appropriate
Each beneficiary or involved pa rty should be m entioned at least once by his or her full nam e and
relationship to the beneficiary.
Progress Summary Notes shall be done every 180 days.
Must include progress toward achieving goals identified in CMP
Determines whether current services should be continued, modified, or discontinued
Should also be done in consultation with the beneficiary
Should be signed, titled, and dated by the CM
™ Special Restrictions:
1. Cannot bill services to juveniles while incarcerated in a DJJ institution, an eval uation center, a local
jail, and/or prison.
2. Case management rendered to individuals in in stitutional placements (except during the last 180 days
of the stay for the purpose of transition and/or discharge planning) are not billable.
3. Cannot bill for DJJ required probation contacts and/or activities.
4. Cannot bill for utilization review or prior authorization for Medicaid.
5. Cannot bill for TCM services fo r adjudicated Juveniles who have not been placed on form al
probation, parole, or under a diversion contract.
™ A FULL FIFTEEN MINUTES MUST BE RENDERED IN ORDER TO BE BILLED.
Service delivery contacts occurring on the same day may be combined until a full unit is reached.
Berkeley MHC
TCM PLAN of CARE
Reviewed
Reviewed
CID#: See CBCL Report
DOB:
Medicaid #:
Client Name:
emergency
procedures
emergency
Primary Dx addressed in Tx: Code and Description
Other Dx
addressed in Tx: Code and Description
with client/family.
procedures with
Identified emergency
client/family
contacts: 211
Identified
Family
Friend
emergency
Needs:
Preferences/agenciescontacts:
to achieve desired outcome:
Other:
211
Family
Developed Personal
Friend
Other
Safety Plan:
Developed
Identify triggers and
Personal Safety Plan:
warning signs that may
Identify triggers
lead to escalating
and warning
signs
Other agencies
involved/contact
person
behaviors/crisis:
that may lead to
escalating
Identify coping skills
behaviors/Crisis:
the client has that can
be utilized to prevent a
Identify coping
crisis:
skills the client has
can be utilized
to prevent this client from achieving
Strengths: (Skills client has to help achieve desired outcome.)
Barriersthat
to Access:
(What will
Preferred
crisis:
desired prevent
outcome?)
interventions for
de-escalating
Preferred
behaviors/crisis:
interventions for
de-escalating
Identify any type of
behavior/crisis:
advance
directive
theclient/family’s needs and preferences. Number each goal and the desired linkage, referral, case
Goals and Planned
Activity:
Include
client to
may
have:
management activity
meet
those goals along with target dates of completion.
Target Date
Client Signature/Date:
SCDMH FORM
JULY 2010 C-201
Case Manager Signature/Date:
Type of Staff
SIX MONTH REVIEW
Name:
TCM PROGRESS SUMMARY for PLAN DATED:
Cid#:
DOB:
Medicaid #:
PROMPTS:
TCM summary should include whether services should be continued, modified or discontinued and done in consultation with the
client/family as appropriate. Include results and follow ups to referrals made during this period.
Case Manager Signature:
Date:
ANNUAL REVIEW
PROMPTS:
TCM summary should include whether services should be continued, modified or discontinued and done in consultation with the
client/family as appropriate. Include results and follow ups to referrals made during this period.
Case Manager Signature:
Reviewed emergency procedures with client/family.
Identified emergency contacts: 211 Family
Friend
Other:
Developed Personal Safety Plan:
Identify triggers and warning signs that may lead to
escalating behaviors/crisis:
Identify coping skills the client has that can be utilized to
prevent a crisis:
Date: