Screening

DESCRIPTION

A behavioral health screening is the process by which a determination of clinical need and/or eligibility for further assessment is made. Screenings for substance dependence and mental health problems are usually brief processes designed to identify people who are at risk of having disorders that warrant immediate attention, or need more comprehensive assessment.

 

Screening is not intended to provide a firm diagnosis, but rather identify the presence of symptoms and propose a measure of urgency. Screening assists in finding clients for whom an immediate response is necessary from those who may be scheduled for further evaluation within routine time frames. Information is collected through face-to-face and/or telephone interviews with the client or collateral.

 

The CMBHS Screening questions are not a script that the Clinician should ask the client word for word. The Clinician must ask the client questions using words the client will understand in order to ensure that the screening results are meaningful. CMBHS gives Department of State Health Services (DSHS) contracted providers a place within the client’s health record to enter information obtained during the screening and document clinical decisions.

 

Before You Start Documenting a Screening

• Your business entity and service location must be of the type that is authorized to perform the screening function.
• You must be assigned a role that authorizes you to document a screening in CMBHS.
• The client must have a profile in CMBHS
• You must be in a client’s CMBHS Health Record, at the Client Workspace.
• Verify that you have the correct client by checking the client’s name and at least one other identifier at the top of the screen before you begin.

Business Rules for Screening

• Some fields in the screening documentation are required, others are optional.
• Required fields are designated by a red ' * ' asterisk .
• An answer must be documented for every question of the Screening Intake and Recommendations sections. Depending on your program type (mental health or substance abuse), all the mental health or substance abuse questions must be answered.
• Both the Substance Abuse and Mental Health Screening Questions are available to any clinician regardless of the clinician’s provider type (MH or SA) or service location. This gives the clinician the opportunity to document clinically relevant information without being limited by provider type or location.
• All screenings for mental health or substance abuse must be documented in the client’s CMBHS health record using the screening function.

How Access the CMBHS Screening Page

To access the Screening page SCR014, you must be in a client’s record, preferably at the Client’s workspace.

From the Clinician’s Workspace

• If you are at your Clinician’s Workspace, select the client from the Client List by clicking anywhere in the row so that the client’s name is highlighted.
• Then CLICK ON the button to the bottom right of the list that says Client Workspace.

 

From the Client’s Workspace

• If you are at the Client’s Workspace for the client you are screening, go to the Client Services Toolbar on the left side of the page.
• Move your pointer over the word Intake and a menu will drop down.
• Select Screening so that it is highlighted and CLICK ON it.

How to Document a Screening

Screening documentation begins with questions about the client’s reasons for requesting services and about the screening process (where it was conducted, who was present etc.). Information about the client’s symptoms is then entered into the Mental Health or the Substance Abuse tabs. The clinician’s conclusions and recommendations for the client are documented in the Recommendations tab.

 

If the client being screened is a person less than 18 years of age, additional questions, labeled Substance Abuse Youth Questions, will also display.

 

The CMBHS Screening document is organized under four headings:

 

Intake

• General Information applicable to all Screening types
• CLICK HERE to go to the 'Intake Screen'

 

Mental Health

• Questions about the client’s mental health applicable to mental health and some substance abuse clients.
• CLICK HERE to go to the Mental Health Questions screen

 

Substance Abuse

• Questions about the client’s substance abuse status applicable to substance abuse and some mental health clients.
• CLICK HERE to go to the Substance Abuse Questions screen

 

Recommendations

• The clinician’s recommendations for the client.
• CLICK HERE to go to the Recommendations screen

 

NEXT,

CLICK HERE to go to the SCREENING, INTAKE TAB