The Client Services Toolbar is on the left side of the CMBHS application. You must have a client record open — to Client Workspace, for example — for all of this toolbar to display. Most of its content is hidden if you are not in a client-related workspace.
The Home option will take you to your default home page. If you have the Security Administrator role, Home will take you to the Security Administrator Workspace. If you have a clinical role, Home will take you to your Clinician Workspace. All other roles will take you to the Welcome page.
Find/Add Client gives you a screen to search for an existing client, or to add a new client.
Client Workspace takes you to a page that summarizes much of a client’s protected health information (PHI).
Intake – Found under the Intake tab are:
Service Planning is used to create the following for a client:
Assessment is used to create:
Service Management is used to create:
o Open Case
o Close Case
Service Documentation is used to create:
o Medication Order
o Medication List
o Medication Service (Single Client)
Consents & Referrals – Found under this tab are:
o Create Consent
o Revoke Consent
Discharge – Under this tab are:
In Clinical Management for Behavioral Health Services (CMBHS), Client Services Functions include those functions that apply to documentation of the clinical aspects of a client’s condition. This includes the services provided and the client’s response. These functions are accessed from the Client Services Toolbar on the left side of your screen.
The Client Services menu, or toolbar, does not fully display until you log into CMBHS, and locate and open a client record. The functions located on the Client Services Toolbar apply to only one client at a time.
There are additional functions for the documentation of services provided to multiple clients located on the Administrative Toolbar at the top of the page.
The Intake functions in Clinical Management for Behavioral Health Services (CMBHS) allow the user to document information collected from the client. This can include information from persons with the client, such as family or friends. As you do this screening, you will document financial information and the client’s clinical and financial eligibility, as well as the client’s admission into services.
For substance use disorder services, the client may be placed on a waiting list if there are no admission slots available at a facility that provides the services needed.
An OSAR may make a reservation for the client at the same facility or another appropriate facility that has an opening soon. You can document Interim services until the client can receive needed services.
For mental health services, clients can also be placed on a waiting list, and interim services can be documented in CMBHS.
On the Client Service Toolbar, click Intake > Screening. On the Screening page, the first tab is Intake.
In the text box, TYPE the client’s Presenting Problem.
Answer the Public Health Risks questions by selecting Yes or No.
From the dropdown lists, select from among the Screening Method, the Interview Setting, and the Referred By options. The Screening Date should be filled with today’s date.
In the next section, General Information, your name will appear in the Performed By dropdown list. If you are documenting this for someone else, select the name of the person who performed the screening from the dropdown list.
Select the Document Status from the dropdown list. Click here for more information about document statuses in CMBHS.
The Document Status Date will be filled with today’s date. You can add any comments about the intake in the Comments text box. When you have completed filling out the page, CLICK the Save button at the top or bottom right side of the screen.
Screening is the place to document the client’s responses to the screener’s questions about a client’s mental health and/or substance use.
Information provided by the client is used in formulating a diagnosis and making recommendations for further assessment. This information is also used to determine the urgency for services.
Answer the questions in the Mental Health Questions section as the client responds to them. Select Yes or No. A text box at the end of Question 6 gives you space to TYPE a comment about the client’s answers.
In the Mental Health Urgency section, select Emergent, Urgent, or Routine, depending on the severity of the client’s mental health issues.
In General Information, the Performed by dropdown list should be set to your name, unless you are documenting for someone else, who performed the assessment. Then, that person’s name should be selected.
Select the Document Status from the dropdown list. The Document Status Date is pre-filled with today’s date. Enter any further comments in the Comments text box. Previously made comments will display below the Comments text box.
If the client is less than 18 years of age, a different set of questions will display in the Mental Health Questions tab.
Click on the Save button at the top or bottom right side of the page when you have completed the page.
The first question asks if the client has used Drugs or Alcohol within the last 30 days. Select Yes or No. If the client answers yes, ask what substance it was, and then select that substance from the dropdown list in question 2. To select more than one substance, press and hold down the Ctrl (Control) key on your keyboard. While holding down the Ctrl key, move your mouse over each substance and CLICK on each substance used by the client.
Complete the remaining questions on the page by selecting Yes or No, according to how the client responds.
In General Information, the Performed by dropdown list should be set to your name, unless you are documenting for someone else. This would be the person who performed the assessment. That person’s name should be selected.
Select the Document Status from the dropdown list. The Document Status Date is pre-filled with today’s date. Enter any comments about the client in the Comments text box.
Answer the question in the Family and Social section to “What is Your Current Living Situation?” from the dropdown list based on the client’s response. If Dependent is selected, answer the additional question to “If Dependent” from the dropdown list. Both are required fields.
This is the place to document the client’s answers to questions about needs for long term services and supports provided by other health and human service agencies.
In Recommendations, select the Preliminary Diagnosis and the Recommendation for treatment from the dropdown lists. CMBHS will pre-fill the Priority Population and Public Health Risk fields. TYPE the reason for the recommended treatment in the Justification text box. Complete the General Information section.
Click on the Save button at the top or bottom right side of the page when you have completed the page.
HHSC and service providers must work together to ensure the protection of confidential client information. Some features built into CMBHS assist in the protection of confidential client information, such as the ability to control access through the use of locations and user roles. It is also necessary to have a consent signed by the client in the record before information can be released electronically.
The service provider is responsible for ensuring, through education and oversight, that only staff with a legitimate need actually see the health record. Just because a user can access a client record does not mean that he or she has a legitimate need to see that client’s health record.
Before a new user accesses any client information in CMBHS, he/she must have a thorough knowledge of state and federal laws and his/her agency’s policies and procedures regarding access to, release of, and protection of client health information. Once you enter CMBHS, you are responsible for ensuring the protection of client information and maintaining the security of your personal computer.
Also, be aware that a consent form, signed by the client, may be necessary before the staff from some parts of your organization can view client records created by another part of your organization.
CMBHS users will be held accountable by the Texas Health and Human Services Commission (HHSC) and other agencies for compliance with all applicable laws related to protected client health information. Assorted methods are used to monitor compliance on the local and state level. CMBHS maintains a record of all client records accessed by users.
The following is a scenario where CMBHS users are warned about Federal law protecting Substance Use Disorder (SUD) clients from having their health record information re-released by a second provider. If an SUD client has given consent for his or her record created at another service provider to be available to your location, the first time any CMBHS user at your location accesses this client’s Client Workspace and attempts to view a consented document, the following popup appears on the screen:
|
42 CFR Re-Release Statements |
|
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. |
|
By clicking ‘OK’ I acknowledge that I have read and do understand the above statement. |
|
OK CANCEL |
If you do not feel you have a thorough knowledge of the laws and rules related to the protection of client health information, do not login to CMBHS to view client information. Contact your supervisor.
A CMBHS Client Health Record consists of three separate but associated components:
Client Profile – The CMBHS Client Profile contains important demographic, identifying, and contact information needed to distinguish one client from another. This ensures that service providers document for the correct client. The Client Profile does not contain any clinical information such as diagnoses or treatments or information about which providers have served the client. It cannot be determined from the Client Profile alone whether a person has received mental health or substance use services or any other services. CMBHS includes Client Profiles for some persons who may have been Medicaid eligible but never requested or received services.
Client Workspace – The Client Workspace provides quick access to important information about the client (e.g., allergies and medications), displays reminder messages about routine documentation that is due, and ensures quick access to documentation about the client. All documents that the user is authorized to view and/or edit can be accessed from the Client Workspace.
Client Documents – All documentation related to the client for all episodes of care can be accessed from the Client Document List at the bottom of the Client Workspace. Client Documents are an assortment of clinical and administrative documents created by a provider (or released to the provider by another CMBHS entity) during and sometimes between a client’s episodes of care.
When CMBHS was first deployed to substance use services providers in 2009, client demographic data and health records were migrated from BHIPS (Behavioral Health Integrated Provider System) and that system was retired.
Beginning September 1, 2013, mental health services client data was imported from the HHS CARE (Client Admission and Registration system) into CMBHS. A CMBHS Client Profile is created for every client whose records are imported into CMBHS or who receives substance use disorder and/or mental health services from a Texas Health and Human Services (HHSC) contracted provider.
If you are trying to locate historical information about a client whose records may have been migrated into CMBHS, but you are not able to locate the information, contact the HHSC CMBHS Help Line at 1-866-806-7806. There are reasons why all records for all clients may not be available in CMBHS, and the Help Line staff are the persons designated to help you with problems such as this.
The Clinical Management for Behavioral Health Services (CMBHS) Client Profile contains demographic and other identifying information about a person. The information in the CMBHS Client Profile may have been entered when the client received services from a Texas Health and Human Services Agency, a Texas Department of State Health Services (DSHS) provider, or it may have been imported from one of the various health and human service agency data systems. These health and human service agency data systems contain the names of clients who have received services in the recent or distant past and also the names of people who are eligible to receive services but have never done so.
The CMBHS Client Profile does not contain information about the type of services received by the client or if, in fact, the client actually received any services. Instead, it displays demographic and identifying information needed to determine the identity of each unique individual to avoid the entry of duplicate clients into CMBHS. Having the correct health records attached to the correct client is critical to ensure that clinicians can access important clinical information when it is needed.
The user must be part of an organization whose contract with HHSC allows the creation of Client Profiles.
The user must be assigned a CMBHS role that allows the creation of Client Profiles in CMBHS. To view a list of Page Rights by Role, click here.
Prior to creating a new Client Profile, be sure you have thoroughly searched CMBHS and have verified that there is not already an existing profile for the client in CMBHS.
Clients are added to the CMBHS system by creating a Client Profile. This can be done at any point in the provider’s workflow such as part of the screening or the assessment process. However, a Client Profile must always be created before anything can be documented in CMBHS about a client
CMBHS requires that the user first Search for a client before a new Client Profile can be created. The user will not have access to the Add New Client button until a Search is conducted.
For Substance Use Disorder services, when a provider has created a CMBHS Profile for a new Client — but has not created any of its own documents for the client and does not have a consent for disclosure of information to obtain records from another provider — the provider will only be able to see the client’s CMBHS Profile and an empty Client Workspace. The provider must create documents and/or obtain them from other providers within the CMBHS system to develop a health record for a client.
You must complete all required data fields for a Client Profile before it can be saved. There is no Draft, Closed Incomplete, or Ready for Review document status for a Client Profile.
|
NOTE: Because there is no clinical information in the Client Profile, it can be viewed by providers without a consent for release of client information signed by the client. Although providers can access Client Profiles in CMBHS, they may do so only in compliance with applicable laws, which includes having a legitimate “need to know” the confidential client information. |
After you search CMBHS for a client and have not located the client, you will see the Add New Client button in the bottom right corner of the page. CLICK on the Add New Client button.
A message will display asking if you are sure you want to create a new client. This is intended to give the user the opportunity to ensure that you are not creating a duplicate client record. CLICK on OK if you want to create a new client in CMBHS.
This will open an empty Client Profile in the Add New Client window where you can document information about the client.
Begin with the first tab and complete all the required information under each tab and then CLICK on Save.
You must complete all required data fields for a Client Profile before it can be Saved. There is no Draft, Closed Incomplete, or Ready for Review document status for the Client Profile.
The Client Profile consists of client information organized under five tabs, which are described in more detail below.
Profile Date
This date represents the date:
Do not assume that the Client Profile date represents the date the client first received services.
When creating a new Client Profile, this field will display today’s date. The Profile Date cannot be a date in the future, but it may be a past date.
If today’s date is not the date the profile was created, you may change the date by CLICKING in the text box and TYPING in the correct date. TYPE in the eight numbers that represent the date and CMBHS will format the date with slash marks for you. Or, if you prefer, TYPE in the Date in the final format with a forward slash between the month and day and the day and year. The result will be a date in the format mm/dd/yyyy either way.
Profile Time
When creating a new Client Profile, this field will display the current system time. The Profile Time cannot be a time in the future but it may be a past time.
Client Name
Users may enter the client name in any case — upper, lower, or mixed.
After the Client Profile is saved, CMBHS will convert the client’s name to all capitals.
CMBHS will remove the prefixes from the client name if you type them into the Client Name text fields and attempt to Save. The prefixes Mr., Mrs., Ms. and Dr. will be removed from the Client Name fields if they are followed by a period.
Enter the client’s first name, middle name (if known, it is not required), last name, and suffix (if known, it is not required).
Date of Birth and Age (Required)
TYPE a Date of Birth into the Date of Birth text box.
TYPE in the eight numbers that represent the date and CMBHS will format the date with slash marks for you, or if you prefer, TYPE in the date in the final format with a forward slash between the month and day and the day and year. The result will be a date in the format mm/dd/yyyy either way.
Be sure to include a zero (0) before the days and months that are single digits (1 through 9).
After a birth date has been entered, the Age will be automatically calculated by CMBHS and will display below the Date of Birth.
If the client does not know or cannot provide his/her Date of Birth, enter an approximate age for the client.
Age Type
This field is calculated by CMBHS and will be consistent with the client’s chronological age.
If the person is less than 18, it will display Youth. If the person is 18 or older, it will display Adult.
City of Birth
Type in the client’s city of birth.
Mother’s Maiden Name (Not Required)
This information is used for matching clients in CMBHS.
If the client does not know or cannot tell you his/her Mother’s Maiden Name, TYPE in Unknown.
Does the client have a Social Security number? (Required)
CMBHS does not require that a Social Security Number be documented for a client, but it does require that either a number, None, or Unknown be entered.
The answer choices are Yes, No and Unknown. Do not leave this field blank or enter a fictitious number.
If you pick Yes, a text box appears in which to enter the social security number.
If No or Unknown are picked, no additional information must be entered.
Local Case Number (LCN) (Conditionally Required)
For substance use disorder services, a Local Case Number (LCN) is not required. However, if you do not assign the client a Local Case Number, CMBHS will insert the client’s unique CMBHS Number into this field. An LCN will display for every substance use disorder services client in CMBHS, whether entered by the provider or CMBHS.
Complete all the required data fields and optional fields that are applicable to this client.
Gender (Required)
Race (Required)
Ethnicity (Required)
Phone Numbers
Address Tab
Contacts Tab
Relationship to Client
Pick from the dropdown list the Contact Person’s relationship to the client.
Pick only one of the following answer choices:
If you pick Other, enter a description of the type of this contact into the text box.
First Name (Required)
MI (Middle Initial) (Not Required)
Last Name (Required)
Legally Authorized Representative (LAR) (Required)
If the Contact Person is the Legally Authorized Representative (LAR) for the client, indicate the type.
CLICK on the arrow to the right of the dropdown list to view the answer choices.
The answer choices are:
Emergency Contact (EC) (Not Required)
Designated Follow-up (DF) (Required for Substance Use Services Only)
Contact Address Information
Complete all the Contact Address information data fields.
Then CLICK on the Add button located near the bottom right corner of the page.
Same as Client (This is not a data field.)
If you CHECK this box, CMBHS that will automatically enter the client’s address information into the Contact Person’s address and phone number fields.
CHECK this box if the Contact Person’s address and phone number are the same as the client’s.
If you CHECK this box, the client’s information will automatically fill in these fields.
Complete the Contacts Tab
After you have filled in all the required Contact Information, CLICK on the Add button. The information will appear in the Client Contact List table. Do not forget this important step. If you do not click the Add button, your information cannot be saved.
If you have Identifiers to document, CLICK on the Identifiers Tab. Follow the directions below. When you have completed documenting the Identifiers and you have completed all other required fields, you can CLICK on Save.
If you have no Identifiers to document and you have completed all the required fields, you can CLICK on Save. Remember, you must complete all required data fields for a Client Profile before it can be Saved. There is no Draft, Closed Incomplete, or Ready for Review document status for the Client Profile.
This tab displays Client Identifiers assigned to the person when they received a benefit or health service from a state funded program, or if they are on a list as eligible for a state funded service or program. The person may never have actually received a state service, but he/she has an identifier. Some identifiers are downloaded to CMBHS from other HHSC data systems such as CARE, or may have been entered manually by a person with the authority to do so.
How to Add or Change an Identifier
Users may add identifiers to this list, change, and remove them.
This tab displays assorted information that does not fit or belong on the other tabs.
The Additional Information Tab is the last Client Profile tab, located after the Identifiers tab.
The data fields on the Additional Information Tab include Marital Status, Custodial Status, Language Preference, Email Address, Estimated Annual Gross Family Income, and Family Size.
Marital Status (Optional)
This field is for the client’s current marital status. You may select only one answer.
The answer choices are:
Custodial Status (Required)
Indicate the client’s custodial status.
Language Preference (Not Required)
Indicate the client’s language preference.
The answer choices are:
If you pick Other, you must also document the client’s language preference in the Other Language Preference text box that displays.
Email Address (Not Required)
If your client has an email address, enter it here.
This field accepts letters, and numbers.
|
NOTE: If the client provides an Email Address, ask if anyone besides the client has access to the address. If others also have access to this email address, discuss with the client the consequences of using the email address for email related to receiving mental health or substance use services. Be sure the client understands the type of information that might be sent by email from your organization. |
Estimated Annual Gross Family Income (Required for mental health services; optional for substance use disorder services)
Family size (Required for mental health services; optional for substance use disorder services)
If you are at the Client Workspace, or if the client’s Name is displayed at the top of page, the quickest way to update the Client Profile is to CLICK on the Client’s name at the top of the page.
This link will automatically open the client’s profile without moving you away from the current page. You can View or Edit the Client Profile from this link.
The Client’s Name displays (underlined and in blue) at the top of every page of the client’s CMBHS Health Record. This ensures quick access to the Client Profile without taking the user away from the page where they are working.
If you are not at the Client’s Workspace and the client’s name is not displayed at the top of page, you must first find the client before his or her Profile can be updated. You can either Search for the client using Find/Add Client or you can pick the client from the Client List on your Clinician Workspace.