Prs Assessment Form

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					                    Charleston/Dorchester Community
                          Mental Health Center




                        CHART FORMATS include:

                     Clinical Record Format for:
                               4 part Chart
                               6 part Chart
                              A/MC Format
               Limited Contact/Short Term Treatment Format




                         Prepared by Janice Rudich, QI
            Reviewed by MR/HIPAA Committee 08/15/06 (rev 02/01/07)




7/20/2011
                                            SECTION A


                        HIPAA RESTRICTION LOG[red paper], if applicable


                    BLUE SHEET (stating discharge date) IF CHART IS CLOSED
            CIS INFORMATION:

                CMHS Client Discharge Form (PDR-2 revised Oct 96)
                CIS Client Data Correction Form (revised March 97)
                Intake Form for CIS (PDR-1 revised May 98)
            MUST BE SIGNED BY CLIENT:

                  Consent to Examinations and Treatment (revised May 98)
                  Consent for Follow-up Contact (dated 11/8/96)
                  S.C. Voter Registration Form (dated Apr 96)
                  Determination of Ability to Pay Reduction Form (revised June 2000)
                    (aka “Financial Statement”)
                  Client Orientation Checklist (effective 3/15/2004)
            Financial Profile
            Fee Status Updates
            Photocopies of: Insurance Card and insurance information
                          Photo ID and/or Social Security Card

            Accounting Log of PHI Disclosures - [on pink paper] ; Effective 7/05-On White
            Paper
            Outgoing & Incoming Requests for Authorization for Disclosure
            HIPAA Forms
                 Authorization to Disclose
                 Restriction Request
                 Request to Amend
            Rural Behavioral Health Services (RBHS) DHHS Form (7/99)
            Billing Adjustment Form Copy[ies] (revised 1/29/01) [Note: original to Data
            Entry]




7/20/2011
                                                      SECTION B

              Information in this section filed in Reverse Chronological Order
            All Information in this section is to be filed in chronological order, i.e., most recent information
            on top. The only exceptions are court papers and Out-of-home placement/hospitalization form.

            BLUE SHEET (stating discharge date) IF CHART IS CLOSED
            SIGNIFICANT TREATMENT EVENTS FORM: Always first document
            (effective 02/01/07)
             [Note: This form replaces both OUT OF HOME PLACEMENT FORM for
            ADULT OR CHILDREN] (effective 01/04)
            OUT OF HOME PLACEMENT: Adult/Children form used prior to 01/04.

            COURT PAPERS:
                Order of Dismissal
                Active Court Order–
                   [Always first document in this section if order is “active”]
                Correspondence to/from Probate Court
                Designated Examiners’ Reports


               All items listed below and filed in this section are to be filed in chronological order,
                             i.e., most recent information on top regardless of subject.

            HOSPITAL INFORMATION:                                OTHER:
                 Continuity of Care information:                     Confidential Fax Transmission
                      Follow-up Process Form &                         Form (Jail)
                      Patient Profile (DMH)                           Magnolia House Assessment
                     Patient Admissions                                Form
                     Information Form                                 Magnolia House Referral
                     State Hospital Identification                     Disposition
                     Summary Sheet                                    Intra-agency Referral Form (rev
                 State Hospital Discharge                             08/24/06)
                   Summary                                            Correspondence from, drawings
                 Hospital Discharge Summaries                         by, patients
                 ER Sheets                                           Incoming Requests for Medical
                 Consultations                                        Records (if prior to June 2003,
                 Documents                                            includes Release of Information
            CORRESPONDENCE:                                            Form and all clinical documents)
                    Outgoing Correspondence*                         Third Party Treatment Plans
                    Incoming Correspondence*                          (e.g., DSS, DJJ, Conners Scale,
                   * Includes records/clinical documentation           CAFAS Profile, etc.)
                     but not request for disclosure itself
                          NOTE: RELEASE THIRD PARTY INFORMATION
                            ONLY WHEN SPECIFICALLY REQUESTED


7/20/2011
                                             SECTION C

                  BLUE SHEET (stating discharge date) IF CHART IS CLOSED

            Physician’s Medication Orders and Service Notes (Revised 1991)
            Physician’s Medication Orders and Service Notes for Algorithm Project
              South Carolina Implementation Medication Algorithm Project [SCIMAP]
            Forms
            Medical Necessity Statement for COMMUNITY BASED WRAP AROUND
            SERVICES (Effective 03/15/2004)(As of 01/06 moved to Section F)
            Semi-Annual Health Evaluation Form/AIMS Quarterly Form expiration
            (yellow form)
            Neuroleptic (Antipsychotic) Consent Form
              Prior to 1/02 in Section A
            Mobile Crisis ER SHEETS
            Physical Assessment Forms
            Adverse Drug Reaction Report
            Laboratory Reports
            Patient Assistance Program
            Prescription copies (optional if date of script greater than three years)
                  [affix to white paper or miscellaneous note sheet]
            Tri-County Crisis Stabilization Center Documentation




7/20/2011
                                                                           4/6 part Chart

                                                SECTION D
                      BLUE SHEET (stating discharge date) IF CHART IS CLOSED
            At discharge:
                   Discharge Summary (revised May 2000)
                   Inactive Procedures Form (dated 8/01) - to be filed under current ITP if
                          client re-engages in service.
            Treatment information:
                   Current Individual Treatment Plan; Now Plan of Care as of 7/06
                    Plan of Care (ITP) Addendum
                    Progress Summaries 90-180 days
                    Progress Summaries 270-360 days
                   Previous [most recently expired] ITPs
                   Clinical Service Notes (CSNs)
                   Behavioral Scale Evaluation (discontinued 8/02)
                   RILS Weekly Notes(revised 9/22/98, revised04/03) PRS Effective02/05
                   RPT Weekly Notes (revised 04/03) PRS Effective02/05
                    PRS(revised 11/05) Replaces RPT & RILS;
                    (Service rendered 3 or more days, then on weekly note in Section E.)
                    (Less than 3 days a week, note done on CSN and put in Section D)
                   Expired ITPs
            At intake:
                   Trauma Forms:
                               SF-12V2 Health Survey
                               TAA/Trauma Assessment for Adults-Brief Revised Version
                               TAA/Trauma for Adults-Interview Version
                               PCL-C
                               Summary Report (see sample) or actual TSCC/Trauma
                                 Assessment Checklist for Children (if not as yet completed)
                                 SEE SECTION F
                               Parent Questionnaire – SEE SECTION F
                      -(resulting from completion of various trauma forms/screenings)

                  Initial Assessment:
                             Clinical Assessment (revised April 99)
                             Clinical Assessment for Adults (eff 09/01/06)
                                --pages 6 & 7 NA for adults
                             Clinical Assessment for Children (eff 10/01/06)
                             Shared Access Screening Form (effective Jan 04)
                             Clinical History and Evaluation Sheet (revised 5/99) CAF
                  Limited Contact Form (eff 09/05 – replaced Short Term Tx Form)
                  Assessment/Mobile Crisis Log Sheet (aka “Triage Sheet”)
                  Initial Contact Form (Child)
                  Miscellaneous Note Sheet


7/20/2011
                                                                          4/6 part Chart


                                             SECTION E


                  BLUE SHEET (stating discharge date) IF CHART IS CLOSED
            MIMS Daily Note, later called STAD, now called CCS (eff 01/05)

            *MH Clubhouse (MH Club) Weekly Note, Now is PRS effective 02/05. New
            Weekly Note effective 11/05.

            *Psychosocial Rehabilitation Services (PRS) Weekly Note (effective 11/05).

            *WRAPS Behavioral Intervention (WRAPS-BI) Daily Note and Sheet, effective
            March 15, 2005

            *WRAPS-Caregiver/Caregiver Services (WRAPS-CG/CGS) Daily Note and
            Sheet, effective March 15, 2005

            *WRAPS-Caregiver/ILS (WRAPS-CG/ILS) Daily Note, effective March 15, 2005
            *WRAPS-Comprehensive Support Services(WRAPS-CSS) Daily Note and
            Sheet, effective March 15, 2005

            Behavioral Scale Evaluation (revised Jan 2000) note: discontinued 8/31/02

       * When this section of the record is full, Section F of the record may be used.
       * WRAPS Medical Necessity Statement should be on top in F section of chart.




7/20/2011
                                                                4/6 part Chart

                                   SECTION F


            BLUE SHEET (stating discharge date) IF CHART IS CLOSED

  *WRAPS Medical Necessity should be on the top of section F effective
  01/06

  CAFAS Profile: Youth Functioning

  RILS/RPT Weekly Notes - effective April 2003, discontinued March 14, 2004
  Trauma Forms [Effective July, 1, 2004]:
                TSCC Summary Report or TSCC/Trauma Assessment
                  Checklist for Children
                TESI-C /Traumatic Events Screening Inventory for Children
                Parent Questionnaire

  * This section is only used if Section E of the record is full for the
  following forms:

  *MH Clubhouse (MH Club) Weekly Note, effective March 15, 2004
   Now PRS [effective 02/05](View Section E for Previous Form)
  *Psychosocial Rehabilitation Services (PRS) Weekly Note, effective March 15,
  2005[Effective 11/05 New Weekly Note] (See Section E)

  *WRAPS Behavioral Intervention (WRAPS-BI) Daily Note Sheet, effective
  March 15, 2005 (See Section E)

  *WRAPS Caregiver/ILS(WRAPS-CG/ILS) Daily Note Sheet, effective March
  15,2005(See Section E)

  *WRAPS-Caregiver/Caregiver Services (WRAPS-CG/CGS) Not Sheet, effective
  March 15, 2005(See Section E)

  *WRAPS-Comprehensive Support Services(WRAPS-CSS) Daily Note and Sheet,
  effective March 15, 2005(See Section E)




7/20/2011
                                A/MC Format
                          [MANILA FOLDER FORMAT]
                         (used primarily for Probation & Parole)

               HIPAA RESTRICTION LOG[red paper], if applicable

          BLUE SHEET (stating discharge date) IF CHART IS CLOSED
   CMHS Client Discharge Form (PDR-2 revised Oct 96)
   Emergency Psychiatry Service Intake Form (revised 5/1/91) or Face Sheet
   CSN’s
   Assessment/Mobile Crisis Log Sheet (Triage Sheet)
   Accounting Log of PHI Disclosures - [on pink paper]
   Outgoing & Incoming Requests for Authorization for Disclosure (revised
   June 2003)
   Other




7/20/2011
                  Limited CONTACT TREATMENT FORMAT
                         [MANILA FOLDER FORMAT]

               HIPAA RESTRICTION LOG[red paper], if applicable


          BLUE SHEET (stating discharge date) IF CHART IS CLOSED
   CMHS Client Discharge Form (PDR-2 revised Oct 96)
   Intake Form for CIS (PDR - 1 revised May 98) or Face Sheet
   Physician’s Medication Orders and Service Notes (revised 1991)
   Limited Contact Form
   CSN’s
   Assessment/Mobile Crisis Log Sheet (Triage Sheet)
   Consent to Examinations and Treatment (revised May 98)
   Consent for Neuroleptic Medications (revised May 93)
   Financial Information
   Photo ID and/or Social Security Card
   Photocopies of Insurance Cards and insurance information
   Accounting Log of PHI Disclosures - [on pink paper]
   Outgoing & Incoming Requests for Authorization for Disclosure (revised
   June 2003)
   HIPAA Forms
        Authorization to Disclose
        Restriction Request
        Request to Amend
   Correspondence
   Other




7/20/2011

				
DOCUMENT INFO
Description: Prs Assessment Form document sample