comprehensive clinical assessment - cardinal innovations
TRANSCRIPT
Page 1 of 18 rev. 20210421
Comprehensive Clinical Assessment Date(s) of assessment:
Clinician completing assessment: Face-to-face time:
Total time spent to complete Record review time:
Member Demographics (Complete this section in its entirety) Member Name: Member ID#:
DOB: Gender: Ethnicity:
Insurance type: Insurance ID #:
Address: Phone #:
Primary language: Referral source:
Legally Responsible Person (LRP):
Participants (Add the names of all the people who are a part of the assessment process. Include those who were face-to-face in the Assessment Participants section and those you reached out to by phone, mail or email in the Collateral Contacts section.)
Assessment participants Relationship to client Date(s) of participation
Collateral contacts Relationship to client Date(s) of participation
Member Name: Member ID#:
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Presenting Problem (Including information from the referral source is recommended; presenting problem should be described in detail.)
Description/reason for referral:
Source of distress:
Associated problems/symptoms (indicate frequency and severity of each):
Medical/General Health History and Current Status (Overview of biological history/issues, physical health, genetic disorders, etc. Coordination of care with primary care physician is highly recommended.)
Current physical health concerns/medical conditions:
Relevant past physical health concerns:
Primary Care Physician Name:
Primary Care Physician Contact Information:
Known allergies:
Genetic disorders:
Physical exam in the past 12 months? (Y/N, include date):
Current pregnancy:
Use of tobacco products/vaping (current or past):
Nutritional needs:
Recent weight loss/gain:
Member Name: Member ID#:
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Speech/hearing/vision impairment:
Past head injuries/TBI:
Immunizations:
Past surgeries:
Eating patterns (as applicable):
Sleeping patterns (as applicable):
Strengths:
Needs:
Risks:
Medication Summary (Include name of current and past medications for physical and psychological health. Fill out each section of chart.)
Name of medication Frequency Dose Adherence Reason for
taking Current or past (include dates)
Side effects or adverse reactions
TBI Screener (If member answers “yes” to question one or two, then complete the Ohio State University TBI Identification below.)
Yes No 1. Have you ever hit your head or been hit on the head, including being told you had a concussion?
Yes No 2. Did you lose consciousness or experience a period of being dazed and/or confused because of theinjury to the head?
Member Name: Member ID#:
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Ohio State University TBI Identification (To be completed if “yes” is answered to either question above, this information needs to be reported to the state here.)
Question Cause, if yes
Yes No
1. In your lifetime have you ever been hospitalized or treated in an emergency room following an injury to your head or neck?
Yes No
2. In your lifetime have you ever injured your head or neck in a car accident or from crashing some other moving vehicle like a bicycle, motorcycle or ATV?
Yes No
3. In your lifetime, have you ever injured your head or neck in a fall or from being hit by something (for example, falling from a bike or horse, rollerblading, falling on ice, being hit by a rock) Have you ever injured your head or neck playing sports or on the playground?
Yes No
4. In your lifetime, have you ever injured your head or neck in a fight from being hit by someone, or from being shaken violently? Have you ever been shot in the head?
Yes No
5. In your lifetime, have you ever been nearby when an explosion or blast occurred? If you served in the military, think about any combat- or training-related incidents
Cause (from above) Did you lose consciousness (LOC)? If yes, how long?
If you had no LOC, were you dazed or did you have a memory gap?
Age at injury
None Less than 30 min
30 min - 24 hrs More than 24 hrs
Yes No
None Less than 30 min
30 min - 24 hrs More than 24 hrs
Yes No
None Less than 30 min
30 min - 24 hrs More than 24 hrs
Yes No
None Less than 30 min
30 min - 24 hrs More than 24 hrs
Yes No
Member Name: Member ID#:
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If more injuries with LOC:
How many? How many greater than 30 minutes?
Longest knocked out? Youngest age of incident?
Have you ever had a period of time in which you experienced multiple repeated impacts to your head (e.g. history of abuse, contact sports, military duty)?
Cause of repeated injury Typical effect Most severe effect Age
Began Ended
Dazed memory gap, No LOC LOC
Dazed memory gap, No LOC Less than 30 min 30 min - 24 hoursMore than 24 hours
Dazed memory gap, No LOC LOC
Dazed memory gap, No LOC Less than 30 min 30 min - 24 hoursMore than 24 hours
Social History (Recreational activities, religious affiliation, community involvement, culture, peer relationships, legal history, sexual orientation, gender identity, immigration, history of discrimination, DSS/DJJ involvement, etc.) The use of ‘NA’ is discouraged for this section.
Description:
Strengths:
Needs:
Risks:
Natural supports:
Cultural considerations:
Member Name: Member ID#:
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Family History (Household members, support systems, family dynamics, military involvement, guardianship status, etc.) The use of ‘NA’ is discouraged for this section.
Description:
Strengths:
Needs:
Risks:
Family history of mental health and/or substance use:
Environment (Living arrangement, issues with living environment, economic issues, availability of food and other resources, transportation issues, safety concerns, etc.) The use of ‘NA’ is discouraged for this section.
Description:
Strengths:
Needs:
Risks:
Member Name: Member ID#:
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Developmental (Milestones reached; information related to IDD, issues during gestation, etc.) The use of ‘NA’ is discouraged for this section.
Description:
Strengths:
Needs:
Risks:
Educational/Occupational History (Grade, academic achievements/problems, disciplinary problems, EC services, employment history, etc.) The use of ‘NA’ is discouraged for this section.
Description:
School/daycare name:
Current grade: Last grade completed if not in school:
Strengths:
Needs:
Risks:
Member Name: Member ID#:
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Employment history:
Psychological/Behavioral Health History The use of ‘NA’ is discouraged for the strengths, risks and needs.
Current behavioral health concerns (psychological symptoms, duration, impact, etc.):
Strengths:
Needs:
Risks:
Additional comments:
Past behavioral health treatment received (include psychiatric hospitalizations): (If member is not able to provide details around the information in this section, provide as much detail as possible.)
Type of treatment (or name of service) Who provided the treatment Dates of
treatment Outcome of Treatment
Member Name: Member ID#:
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Substance Use History (Complete this section in its entirety, including as many details as possible.)
No known history of substance use
Drug Age of 1st use
Frequency of use Amount used Route Last use
Withdrawal symptoms
Problems related to use
Caffeine
Nicotine
Alcohol
Cannabis
Cocaine
Hallucinogens
Ecstasy
Inhalants
Opiates
Barbiturates
Benzodiazepines
Other:
Additional Comments:
ASAM Severity Profile (Only for those with a diagnosis of substance use disorder(s))
Dimension 1: Acute Intoxication and Withdrawal Potential
Dimension 2: Biomedical Conditions and/or Complications
Dimension 3: Emotional, Behavioral, or Cognitive Conditions and/or Complications
Dimension 4: Readiness to Change
Dimension 5: Relapse, Continued Use, or Continued Problem Potential
Dimension 6: Recovery Environment
ASAM Placement Level
Member Name: Member ID#:
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Trauma History (Recommend use of trauma screening tool, ask about any significant stressors, or any event that caused significant stress.)
Abuse history (physical, sexual, emotional):
History of neglect/basic physical needs not met:
Exposure to domestic/family violence:
Exposure to community violence:
Family history of violence and/or suicide:
Serious accident/illness/medical procedure:
Exposure to school violence and/or bullying:
Exposure to drug/substance abuse or related activity:
Incarceration and/or witnessing arrest of family/caregiver(s):
Traumatic death of a loved one:
Immigration trauma:
Natural disaster/war/terrorism:
Separation from/change in primary caregiver:
Homelessness:
Other significant stressors:
Symptoms related to trauma:
Additional comments:
Member Name: Member ID#:
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Risk Assessment Current risk of harm to self or others:
Suicidality: Thoughts Ideation Intent Plan Gestures Means
Homicidality: Thoughts Ideation Intent Plan Means
History of harm to self or others (suicidal or homicidal ideation/intent/behaviors):
Risk-taking behaviors:
Access to firearms/weapons:
Strengths/protective factors:
Crisis/safety plan (if applicable):
Member Name: Member ID#:
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Mental Status Exam (Based on observations of the member during the assessment, use comment sections for any clarification that may be needed.)
Orientation
Person: Place: Time:
Situation:
Comments:
General Appearance
Appropriate forage/development
Overweight Disheveled
Stiff Stooped
Well-groomed Dirty
Other:
Comments:
Attitude
Cooperative Resistant Hostile
Reserved Negative Sarcastic
Suspicious Guarded
Pleasant Open
Appropriate to context Dependent Passive aggressive
Other:
Comments:
Attention/concentration
Appropriate to context Focused Distracted Inattentive
Other:
Comments:
Member Name: Member ID#:
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Motor Activity
Appropriate to context Hyperactive
Fidgety Lethargic
Motor/muscle tic(s) Restless
Repetitive acts
Other:
Comments:
Speech
Appropriate forage/development
Slurred Slowed
Mumbling Rapid
Pressured Soft
Tangential Impoverished
Other:
Comments:
Eye Contact
Appropriate to context Intense
Avoidant Fleeting
Intense/Unwavering Sporadic
Other:
Comments:
Affect (observed)
Appropriate to context Congruent Incongruent
Fearful Anxious Sad
Apathetic Flat Constricted
Labile Euphoric
Withdrawn Agitated
Other:
Comments:
Member Name: Member ID#:
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Mood (experienced)
Appropriate to context Depressed
Elevated Anxious
Irritable Labile
Hopeless
Other:
Comments:
Thought Process
Unremarkable Coherent
Incoherent Tangential
Circumstantial Loose association
Confused
Other:
Comments:
Thought Content
Appropriate for age/development Ideas of reference Paranoid Flight of ideas
Other:
Judgment: Appropriate for age/development Impaired
Insight: Good Average
Poor Denies/minimized
Blames others Limited abstract reasoning skills
Comments:
Perception
Appropriate for age/development Derealization Depersonalization
Other:
Hallucinations: Auditory Visual Tactile Olfactory
Delusions: Grandiose Paranoid
Other:
Comments:
Member Name: Member ID#:
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Behavior (describe in comments)
Appropriate toage/development
Self-harm Impulsive
Aggressive – physical Aggressive – verbal
Bizarre
Other:
Comments:
Cognitive Concerns
Appropriate toage/development
Comprehension Short term memory
Long term memory I/DD
Other:
Comments:
CALOCUS/LOCUS
CALOCUS Level of Care Recommendation (For children only—ages 6 and up)
Dimension I: Risk of Harm
Dimension II: Functional Status
Dimension III: Co-Morbidity
Dimension IVA: Recovery Environment “Stress”
Dimension IVB: Recovery Environment “Support”
Dimension V: Resiliency & Treatment History
Dimension VI A: Acceptance & Engagement (Child/Adolescent) Dimension VI B: Acceptance & Engagement (parent/caretaker) Total Score (On IV and VI, use only the higher score of A or B to total)
Level of Care N/A
Alternate Level Recommended
Reason:
Member Name: Member ID#:
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Additional Assessment Scores/Results (Any standardized measures used)
Name of screener/tool Outcome
Diagnoses (From DSM-5; include the full name and ICD-10 code for each; include known behavioral and physical health diagnoses.)
Member Name: Member ID#:
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Summary, Case Formulation, and Recommendations Summary and Case Formulation (Summary of presenting problems, life domains, screening tools, diagnosis and justification of diagnosis, readiness for change, etc.)
Recommendations (i.e., Additional assessments, services, supports, or treatment based on CCA; interventions recommended to address factors contributing to behavior/symptoms. Consider clinical services and/or non-paid supports needed for child and/or adult caregiver, parenting and caregiving strategies, safety planning, educational setting recommendations, social/recreational activity recommendations, medical assessment/coordination, etc.)
Service Recommendations (other recommendations listed above) (Note: If not familiar with the criteria for some of the services below, in the “other” describe the treatment elements clinically indicated; ex. In-home services, crisis response availability, family skill development.)
Trauma-focused cognitivebehavioral therapy (TF-CBT)
Family therapyMedication management Day treatmentMultisystemic therapy Residential Level I-Family Type Residential Level II-Family Type Residential Level III-Group Home Psychological evaluation
Substance Abuse IntensiveOutpatient Program (SAIOP)
Family Centered Treatment (FCT) High Fidelity Wraparound Individual therapy Group therapy Respite Intensive In-Home services Supported Employment (16 and up) Residential Level II-Program Type
Residential Level II-Family Type(MH/IDD)
Psychiatric residential treatmentfacility
Parent assessment Detox In Home Therapy Services (IHTS) Trawnsitional Living (b)(3)
Other:
Member Name: Member ID#:
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Justification of Service Recommendations (Summary of assessment results that support the need for the recommended service(s)/level of care; cite how specific criteria for the level of care noted above is met for the member; for enhanced services, explain why lower levels of treatment were determined not to be appropriate.)
Signatures and Dates
Signature and credentials of clinician completing assessment Date