Medi-Cal Documentation Flashcards
What are 5 Cultural Factors in Assessment?
Ethnicity, Immigration, Language, Religion, Sexual Orientation
What are 5 examples of Client Strengths in Assessment?
Skills, Personality traits, intelligence, resiliency, insight
What are 8 Risk Factors in Assessment?
Suicidal, Trauma, Neglect/Abuse, Domestic Violence, Crime/Gang Involvement, Substance Abuse, Cognitive Impairment, Risk of homelessness.
What are 15 categories of Mental Status Exam in Assessment?
Appearance, Motor, Behavior, Consciousness, Orientation, Speech, Affect, Mood, Though Process, Delusions, Hallucinations, Intellect, Memory, Insight, Judgment.
What are 3 essential criteria encompassed by Medical Necessity?
A. Included Diagnosis (Axis I or II)
B. Functional Impairment
C. Related Interventions
What are 8 elements of assessment?
- Presenting Problem
- Risk Factors
- Client Strengths
- Mental Health History
- Psychosocial History
- Medical History
- Mental Status Exam (MSE)
- Cultural Factors
What is the timeline for Initial Assessment?
60 days
What is the timeline for Mental Health Assessment Update?
yearly
Why do we do Assessment? (3 reasons)
To arrive at:
- Five-axis diagnosis
- Diagnosis must be signed by LPHA
- Drives Treatment Plan
What are the 5 elements of the MH Treatment Plan?
- Desired Results
- Problem
- Goal
- Objectives
- Interventions
What constitutes the Problem on MH Treatment Plan?
The symptoms and/or behaviors driven by diagnosis.
i.e. “Fidgety, forgetful, can’t focus, easily distracted, interrupts others all the time which is interfering with school”
What constitutes Desired Results on MH Treatment Plan?
client’s own words
What constitutes Goal on MH Treatment Plan?
Outcome of mental health services from a client-therapist collaboration, focusing on the symptoms and/or behaviors. Must be observable and/or quantifiable.
i.e. Decrease interruptions from 5x/day to 1x/day in order to maintain academic placement.
What constitutes Objectives on MH Treatment Plan?
What the client will do to accomplish the goal.
i.e. Client will attend weekly ADHD sx management group, will take meds as prescribed; parents will attend bi-monthly parenting group.
What constitutes Interventions on MH Treatment Plan?
What staff will do to help client achieve the goal.
i.e. Staff will co-lead ADHD sx management group, will provide one-to-one CBT bi-monthly, will consult with psychiatrist as needed, will link parents to parenting group in order to assist the child in maintaining their academic placement for the next 12 months.
