Mental Health Medi-Cal: 11 Required Assessment Elements

Transcription

1 Mental Health Medi-Cal: 11 Required Assessment Elements 1. Presenting Problem 2. Relevant Conditions and Psychosocial Factors 3. Mental Health History 4. Medical History 5. Medications 6. Substance Exposure/Substance Use 7. Client Strengths 8. Risks 9. Mental Status Examination (MSE) 10. Complete Diagnosis 11. Additional Clarifying Formulation Information (as needed) Other Funded Services (ps97-99). Available at: Page 1 of 12

2 "Presenting Problem" means the beneficiary s chief complaint, history of presenting problem(s) including current level of functioning, relevant family history and current family information. the first of eleven required elements for an assessment Other Funded Services (p97). Available at: Page 2 of 12

3 "Relevant Conditions and Psychosocial Factors" means the factors affecting the beneficiary s physical health and mental health including, as applicable; living situation, daily activities, social support, cultural and linguistic factors, and history of trauma or exposure to trauma. the second of eleven required elements for an assessment Other Funded Services (p97). Available at: Page 3 of 12

4 "Mental Health History" means previous treatment, including providers, therapeutic modality (e.g., medications, psychosocial treatments) and response, and inpatient admissions. If possible, include information from other sources of clinical data such as previous mental health records and relevant psychological testing or consultation reports. the third of eleven required elements for an assessment Other Funded Services (p97). Available at: Page 4 of 12

5 "Medical History" means relevant physical health conditions reported by the beneficiary or a significant support person. Include name and address of current source of medical treatment. For children and adolescents the history must include prenatal and perinatal events and relevant/significant developmental history. If possible, include other medical information from medical records or relevant consultation reports. the fourth of eleven required elements for an assessment Other Funded Services (p97). Available at: Page 5 of 12

6 "Medications" means information about medications the beneficiary has received, or is receiving, to treat mental health and medical conditions, including duration of medical treatment. The assessment must include documentation of the absence or presence of allergies or adverse reactions to medications and documentation of an informed consent for medications. the fifth of eleven required elements for an assessment Other Funded Services (p98). Available at: Page 6 of 12

7 "Substance Exposure/ Substance Use" means past and present use of tobacco, alcohol, caffeine, CAM (complementary and alternative medications) and over-the-counter drugs, and illicit drug. the sixth of eleven required elements for an assessment Other Funded Services (p98). Available at: Page 7 of 12

8 "Client Strengths" means the documentation of the beneficiary s strengths in achieving client plan goals related to the beneficiary s mental health needs and functional impairments as a result of the mental health diagnosis. the seventh of eleven required elements for an assessment Other Funded Services (p98). Available at: Page 8 of 12

9 "Risks" means the situations that present a risk to the beneficiary and/or others, including past or current trauma. the eighth of eleven required elements for an assessment Other Funded Services (p99). Available at: Page 9 of 12

10 "Mental Status Exam (MSE)" means a mental status exam. the ninth of eleven required elements for an assessment Other Funded Services (p99). Available at: Page 10 of 12

11 "Complete Diagnosis" means a diagnosis from the current ICD-code must be documented, consistent with the presenting problems, history, mental status examination and/or other clinical data; including any current medical diagnoses. the tenth of eleven required elements for an assessment Other Funded Services (p99). Available at: Page 11 of 12

12 "Additional Clarifying Formulation Information" means additional clarifying formulation information, as needed. the eleventh of eleven required elements for an assessment Other Funded Services (p99). Available at: Page 12 of 12