DESCRIPTION
Who Has a CMBHS Client Health Record?
A Clinical Management for Behavioral Health Services (CMBHS) Health Record is created for every client that receives mental health or substance abuse services from a Texas Department of State Health Services (DSHS) mental health or substance abuse contracted provider and for others who may never have received services but have been found eligible.
When CMBHS was first deployed, client health records were migrated from the BHIPS (Behavioral Health Integrated Provider System developed and maintained by TCADA & DSHS), CARE (Client Admission and Registration system developed and maintained by TDMHMR & DSHS) and other HHSC data systems to CMBHS. Records for all clients and all the past information you may need about a client may not be available in CMBHS for many reasons. If you are not able to locate information you believe should be in CMBHS,
Before You Start
- Before you attempt to access any information in CMBHS about a client, beware that the Client Profile does not contain clinical information about the client.
- It cannot be determined from the Client Profile whether or not the client received mental health or substance abuse services from Department of State Health Services (DSHS), only that the client received some type of service at some point in time, causing a Client Profile to be developed for them.
- The only identifiers that you can view are either not specific or they are numbers entered by your provider organization.
A CMBHS Client Health Record consists of 3 integrated components:
1. Client Profile (Client Profile) page #CLI015
This section of the electronic health record (EHR) contains important demographic, identifying and contact information about the client. The Client Profile contains the information needed to distinguish one client from another to avoid the creation of duplicate records and ensure access to the correct client information needed to provide appropriate and safe service delivery.
The Client Profile does not contain clinical information such as a diagnoses or recommendations. It cannot be determined from the Client Profile whether or not the client received mental health or substance abuse services from Department of State Health Services (DSHS), but rather that the client received a service from the Texas Health and Human Services system at some point in time, resulting in the creation of a Client Profile. Unless you have a valid Authorization to Release Health Information in CMBHS, the identifiers that you can view in the Client Profile are not specific to service type.
2. Client Workspace (Client Health Record Face Sheet) page #CCP007
Each client health record has a face sheet (the Client Workspace) that is the primary point of access to view and put information into the client’s health record. The Client Workspace displays important information about the client and ensures quick access to editing existing records. Also available are messages about documentation that is due.
3. Client Documents (All Documentation related to the client for this episode of care) page #CCP007
Client Documents are an assortment of clinical and administrative documents created during a client’s episode of care. The documents facilitate continuity of care and provide data for state and federal reporting. The data is also available for the provider’s use to manage and improve services.
NOTE:
- Because there is no clinical information in the Client Profile, it can be viewed without a signed Consent for Release of Information from the client on a need to know basis only.
CAUTION:
- Each and every CMBHS User is responsible for having extensive knowledge of state and federal laws regulating access to and protection of client identifying information in the CMBHS system and will be held accountable by DSHS (and others) for following all of these rules all of the time.
- If you do not have knowledge of the laws and rules related to the protection of client health information, contact and discuss this with your supervisor prior to viewing any client information in CMBHS.
Confidentiality of Client Health Records
You may access the client’s health record by using the Find/New Add Client function to locate a client information in CMBHS.