Annual Clinical Update for Children
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1 Annual Clinical Update for Children NAME / MRN BILLING Program Name: FAC/PROG: Date: Provider #: Minutes: Code Activity: 331 Assessment 580 Lockout Location of Services: (Please check one) 1 Office 5 School 11 Faith-based 15 LicCommCareFac (Adult) 19 Res Tx Ctr (Child) 2 Field 8 Cor Fac 12 Healthcare 16 Mobile Service 20 TeleHealth 3 Phone 9 Inpatient 13 Age-spec Comm Ctr 17 NonTradSvcLoc 21 Unknown 4 Home 10 Homeless/Shelter 14 Client s Job-site 18 Other Service Strategies: (Please check up to three, if applicable) 50 Peer/Fam Deliv Svcs 53 Supportive Education 56 Ptnrshp: Soc Svcs 59 Integrated Svcs: MH-Dvlp Disabled 51 Psych Education 54 Prtnrshp: Law Enfcmt 57 Ptnrshp: Subs Abuse 60 Ethnic-Specific Service Strategy 52 Family Support 55 Ptnrshp: Health Care 58 IntSvcs : MH / Aging 61 Age-Spec Svc Strategy 99 Unknown Is the client pregnant? Yes No (If yes, please document how service was pregnancy-related) Interpreter Name of Interpreter: Language service provided in other than English: Spanish Other Identifying Information: Name: Age: DOB: Address:_ Phone Emergency Contact/Name & Phone: MH Provider: Current Mental Health Functioning: (Include current symptoms, improvements in functioning, on-going functional impairments, updated psychiatric treatment/hospitalizations and other pertinent changes in past year) Family/Social/Economic Update: (Include living situation, legal status, income, socialization, work or educational activity, judicial involvement, support system and any changes in life circumstances.) MHC(SC)_065 Rev Annual Clinical Update for Children Page 1 of 5
2 Educational Update: (Include any updates to child s school placement, attendance, performance, grades, special education, or other school updates) Medical History: Primary Care Provider: Last Physical Exam: Last Dental Exam: Psychiatrist_ Location List all Medical Conditions/Physical Health Update: Has the child had any allergic/serious reactions to medication(s)? No Yes (if so, please describe): Has the child had any NON medication allergies (food, pollen, bee stings, etc.)? No Yes (if so, please describe): Med Compliant? Yes No Unknown List name of medication(s) client is taking at this time. (List all current meds including OTC, herbal, and homeopathic. Include start date/dose/frequency.) Risk Behaviors: Danger to Self (Intent, Plan, Means): Past: Danger to others: (Intent, Plan, Means): Past: Grave Disability (unable to make use of available resources): 5150 Initiated CPS Referral Tarasoff Arrests/Incarcerations in last 12 months MHC(SC)-065 Rev Annual Clinical Update for Children Page 2 of 4
3 Substance Use: No Past Substance Abuse Actively Using Substances Currently Clean & Sober for: Unknown Please list all substance being used or list current treatment interventions. Please check all substances used in the past 6 months: Past Present Frequency Alcohol Amphetamine Caffeine Cocaine/Crack Designer Drugs (GHB, PCP, Ecstasy) Hallucinogens (LSD, Mushrooms) Inhalants (Paint, Gas, Aerosols) Marijuana Opiates (Heroin, Opium, Methadone) Over the Counter Pain Killers (Oxy, Norco, Vicodin) Other Comments: Mental Status Exam: General (Appearance, attitude, behavior, speech): Orientation: Mood/Affect: Memory: Thought Process: Thought Content: Insight/ Judgment/ Impulsivity: Additional Observation: MHC(SC)-065 Rev Annual Clinical Update for Children Page 3 of 5
4 Diagnostic Impression: DSM 5 Diagnosis, ICD 10 Code and Narrative DSM-5 Diagnosis: (Primary) AND ICD-10 Code: Diagnosis Title/Narrative: DSM-5 Diagnosis: (Secondary) AND ICD-10 Code: Diagnosis Title/Narrative: DSM Diagnosis by: (Name of Diagnosing Clinician/Licensure) Justification for Continued Care Services (Use Data Continuation Page if needed) Discharge Plan Update: (Clinical Presentation) (Use Data Continuation Page if needed) Staff Signature/License Printed Name Date Co-Signature/License Printed Name Date Data Entry Clerk Initials MHC(SC)-065 Rev Annual Clinical Update for Children Page 4 of 5
5 Space for Data Continuation (Specify which item you are continuing from) MHC(SC)-065 Rev Annual Clinical Update for Children Page 5 of 5
Initial Clinical Assessment for Children
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