Recommendations Tab

DESCRIPTION

The Clinician’s recommendations are documented in this section of the Clinical Management for Behavioral Health Services (CMBHS) Screening.

On the Recommendations Tab, you will see the following fields:

Recommendation

(Required for substance abuse and mental health services).

• If the screener has more than one recommendation, select the recommendation that should be implemented next or that reflects the client’s most urgent need.
• CLICK ON the drop down menu arrow to the right of the box to select the recommendation from the drop down list.

View recommendation drop-down list

• Put on wait list;
• Sent for Mental Health Treatment;
• Sent for community services;
• Sent for education;
• Sent for formal mental health assessment;
• Sent for formal substance abuse assessment;
• Sent for medical evaluation;
• Sent for substance abuse treatment;
• Sent home

Justification

(Required for substance abuse and mental health services)

• Next, TYPE IN your Justification for the recommendation in the text box next to Justification.
• CLICK IN the box to begin typing.
• You are limited to 1000 characters in this box so adjust your answer to ensure it will fit.
• If you enter more than 1000 characters, your typing will stop displaying and you will receive an error message when you try to save the page.

Preliminary Diagnosis (Required for substance abuse only)

• This field will display only for clients being screened for Substance Abuse Services. When screening for mental health services, a 'Preliminary Diagnosis’ is not documented.
• The answer choices includes DSM – IV Diagnoses related to substance use .
• The list of answer choices also includes “No Diagnosis” and “Diagnosis Deferred”.
• You may select only one Preliminary Diagnosis.
• To select a 'Preliminary Diagnosis’, CLICK on the Preliminary Diagnosis drop down menu on the right.
• Then CLICK ON the appropriate selection. Use the sliding bar to SCROLL through all the possible selections.

Performed by

(Required for substance abuse and mental health services)

• If you are the staff person that conducted the screening, select your own name from the drop down list.
• If you did not screen the client but are functioning in a data entry capacity, choose the name of the clinician that performed the screening from the drop down list. Your name will be displayed in the audit information at the bottom of each page.

Document Status

(Required for substance abuse and mental health services)

Next, select the Document Status described below

Draft

• This status indicates that the CMBHS user has started to enter data about a screening into the client’s health record but the task must be interrupted and completed at a later date.
• Any user with a role that allows them to enter data into a document may put that document in draft status and at a subsequent date continue the data entry process.

Ready for Review

• This status is used by a CMBHS user whose role does not allow him/her to put a document into “Closed Complete" status.
• When the user has finished entering information into the screening document, it must be reviewed by the designated supervising staff, who can put the screening in “Closed Complete” status.

Closed Complete

• This status indicates that the user has completed all data entry in this document.
• After selecting the Closed Complete Status and then clicking on SAVE, no further data entry (additions, changes, deletions etc) are possible.
• If the user needs to make any change to the screening document after it has been “closed complete” and update screening must be.
• Note: Once the 'Closed Incomplete' Status selected and then SAVE is then clicked, no further data entry (additions, changes, deletions etc.) is possible.

Closed Incomplete

• This status indicates that the user has not completed all data entry required in this document but no further data is expected.
• This status is differentiated from the draft status in that although data entry is incomplete, the client’s circumstances are such that no further information will be entered in the document during this episode of care.
• After selecting the Closed Incomplete Status and then clicking on SAVE, no further data entry (additions, changes, deletions etc) are possible.

Document Status Date

(Required for substance abuse and mental health services)

• The document status date is auto populated on this screen as of today's date and cannot be edited.
• This date field is automatically filled with today’s date.
• The user may change the date to a past date when the screening was actually conducted with the client but it may not be a future date.

Comments (Optional)

• You may enter any additional information related to this page or a field into the Comment box.

Audit Information

• After the Screening has been Saved, the following Audit Information will display at the bottom of the page.
• This information is view only and cannot be changed by the user.
• If you believe there is an error in the Audit Information, contact your Local CMBHS Administrator.
  • Created By
    • The Name of the User that started the Screening will display here.
  • Created Date
    • Date Document was first created
  • Last Saved By
    • The Name of the User that Last Saved the Screening will display here.
  • Last Saved Date
    • Date document was last entered, edited and saved

To Save the Screening and Close

• Next, CLICK ON the Save button.
• You will either see a “Successfully Saved” or an error message. Most error messages are caused by the Edit function in CMBHS, when the user has not completed all required fields properly.
• CLICK OK and the message will close. CLICK HERE for more information about Error Messages and the Editing process.

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FINANCIAL ELIGIBILITY