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1 County of Sacramento Department of Health and Human Services Division of Behavioral Health Services Policy and Procedure Policy Issuer (Unit/Program) Policy Number QM QM Effective Date Revision Date Title: Functional Area: Health Questionnaire Chart Review (Adult/Children /Youth) Non-Hospital Services Approved By: (Signature on File) Signed version available upon request Alexandra Rechs, LMFT Program Manager, Quality Management PURPOSE: The purpose of the Electronic Health Questionnaire (EHQ) is to provide an opportunity to review the client s physical health history. In addition, the EHQ allows the Provider to determine if a referral to a Primary Health Care Provider might be appropriate or warranted. DETAILS: Procedure: 1. The completed EHQ is part of the Electronic Health Record (EHR) in the Clinical Workstation (CWS) as part of the client s chart 2. The clinician/personal service coordinator is responsible for having a completed EHQ as part of the Electronic Health Record (EHR) for all clients upon admission to the Mental Health Plan (MHP) Provider s program, otherwise they risk fiscal disallowance. Parents or caregivers may provide the clinician/personal service coordinator with information to complete the EHR. 3. The provider shall review the EHQ with the client, parent/caregiver to ensure that all areas are completed and accurate. 4. The EHQ must be completed at start of services within 60 days of the Provider Start Date. 5. The EHQ Update must be completed annually in conjunction with the rest of the clinical bundle which will indicate a continued authorization. The following programs have additional steps to request for re-authorization and must submit request for re-authorization to Access in addition to completing a Client Plan: Assessment only, Psychological Testing, Day Rehabilitation Services, Day Treatment Intensive Services, Therapuetic Behavioral Services, Enrolled Network Provider, Out of County Contracts, and ECT. The EHQ update may be completed upon re-opening a client to the same provider if the last EHQ had been completed within last 6 months. 6. When current health concerns are evident, the provider refers the client to a Primary Health Care Provider or the attending Psychiatrist for physical evaluation and documents this referral in the Progress Notes. 7. The MHP prohibits inappropriate mental health service referrals to a primary care provider for clients who meet Specialty Mental Health Services medical necessity criteria. Disputes should be referred to the appropriate county MHP medical director or designee. Page 1 of 5
2 8. For legally emancipated Minors (age 15 and up) and minors in RCL placement or foster care ages 16 and up who are mature enough to participate in the services provided and are aware of their physical healthcare history the clinician/personal service coordinator shall complete the correct Core Assessment (children/tay, adult) to enable the EHQ based on the client s age range. Required Reporting Items: The following items must be addressed in the EHQ. These elements are part of the required MHP audit protocol and contract for a complete bio-psychosocial assessment. 1. Relevant physical health conditions must be identified and updated as appropriate with referral to a Primary Care Physician as needed or appropriate. 2. If the client and/or caregiver indicates that they currently do not have a Primary Care Physician, the provider must make efforts to provide information and support to ensure that linkage has been made. 3. Allergies and adverse reaction(s) to medications, or lack of known allergies. 4. Child/Youth HQ must include pre-natal and peri-natal events and a complete developmental history. GENERAL PROVISIONS: Based on client s age range, select the applicable HQ that better fits the client s needs (Adult Health Questionnaire and/or the Child/Youth Health Questionnaire). Legally emancipated Minors (ages 15 and up) and minors in RCL placement, or foster care ages 16 and up who are mature enough to participate in the services provided and are aware of their physical healthcare history, may opt for the completion of the Adult Health Questionnaire in lieu of the Child/Youth Health Questionnaire. The Adult Health Questionnaire (AHQ) shall include the following information. 1. Date. The date the form is completed. If it takes more than one day to complete the form, this date should reflect the date the form was started. 2. Gender. This is pre-populated based on the client s identified gender assigned at birth in the, Update Client Data section of the chart. Based on this selection, applicable information will be prepopulated by Avatar. 3. Currently seeing a primary physician. Identify with a yes or no if the client is currently seeing by a primary physician. 4. Last Doctor Visit. Indicate the timeframe from the last doctor s visit as reported by the client. In addition, specify the reason for the last doctor visit. 5. ER visits. Mark either yes, no or unknown to identify any ER visits conveyed by the client in the preceding 12 months. Provide details for the ER visits. Page 2 of 5
3 6. Last Colon Screening. Indicate the timeframe from the client s last Colon Screening or if they have never had a Colon Screening. 7. Conditions. Identify any known medical conditions that the client has ever experienced. Indicate the onset and details and describe the medical conditions and current treatment the client is receiving. 8. Gender specific questions Choose the client s gender specific questions. Provide information describing any existing health conditions, dates (to the best knowledge of the client/caregiver) and current treatments. The gender specific questions are generated based on the client s identified gender assigned at birth in the, Update Client Data section of the chart. 9. Dental Indicate the timeframe from the last visit to the dentist and whether yes, no or unknown if the client has any dental problems, ever had oral surgery or has any dental problems. 10. Hearing Indicate yes, no or unknown if the client has any hearing problems. Provide details on the hearing problems. Indicate the timeframe from the last hearing test and provide details on the hearing test and hearing issues. 11. Vision Indicate yes, no or unknown if the client has any visual problems, timeframe from the last exam and whether yes, no or unknown if the client wears any type of corrective lenses/ contacts, and provide any details on vision problems. 12. Caffeine and Tobacco Indicate the client s caffeine intake and/or tobacco intake, select the client s smoking habits and identified tabacco products that the client uses. Solicit from client if is interested in a smoking cessation program. Provide detail on tobacco use. The Child/Youth Health Questionnaire (CHQ) shall include the following information. 1. Date. The date the form is completed. If it takes more than one day to complete the form, this date should reflect the date the form was started. 2. Sources of Information/Relationship/Phone Identify the name of the person providing the information for the CHQ/Youth form, the relationship to the child and /or other source of information. 3. Last physical. Provide information related to the child s last physical exam, and provide with date if known. 4. Current weight/length/height. Provide information related to the child s current length, height and weight at time of completion of this form. 5. Physical growth on target Solicit from the parent/caregiver information to describe if the child s physical growth is on target. Mark either yes, no or unknown. 6. Immunizations up to date. Indicate whether or not the child s immunizations are up to date. Page 3 of 5
4 7. General medical conditions. Select all general medical conditions that the child and caregiver identify. Provide comments on the general medical condition and / or reasons for all unknowns and plan for follow-up. Mark either yes, no, or unknown to identify any known medical problems or conditions that you feel the doctor should know about. Comment on the medical problems. Indicate yes, no, or unknown to identify if the child/youth has ever experienced any: history of auto accident and/or injury, broken bones, accident prone, episodes of easy bruising, bleeding or any other medical problems or conditions and any family medical history. Provide comments when applicable or indicate None in the comment box. 8. Hospitalization. Indicate yes, no, or unknown to identify if the client has had any ER visits. Describe any ER visits and details. Indicate yes, no, or unknown if client has had recent medical hospitalizations. Describe any past medical (not psychiatric) hospitalizations and reasons the child has been hospitalized. Indicate yes, no, or unknown if the client has had surgeries. Describe any surgeries providing details. Describe any NICU experiences and specifics. 9. Pregnancy Information Indicated circumstances surrounding the mother s health during pregnancy by addressing following areas: Describe if pregnancy was planned and describe any relevant comments on pregnancy planning. Trimester prenatal care was started. Indicate the mother s age at start of pregnancy and duration of pregnancy (months). Describe the mother s health or any known conditions that affected the mother during pregnancy. Indicate if AOD exposure in-utero, and any complications of pregnancy. Indicate if there was any trauma during pregnancy, and it was a premature birth. Mark unknown if the information is not known and describe the rationale. 10. Labor/Delivery/Birth History Describe the duration of labor, anesthesia used; Describe any medication used during birth. Child s birth weight and length; Amount of time mother and child spent in the hospital; Indicate whether or not the child was breast fed and for how long; and indicate any other difficulties or peculiarities related to the delivery, appearance or behavior at birth or during pregnancy. Indicate the name and address of the hospital. 11. Birthing Complications Identify any known birthing complications. Comment and explain in detail any complications as needed. 12. Neonate Identify any known problems during the first 30 days of life and describe the neonatal issues. Comment on pregnancy issues as needed. 13. Developmental History Indicate the age in which each event occurred and explain if necessary. Indicate if there were any developmental tools used to support client in developmental assessment. Indicate yes, no, or unknown if the client is meeting developmental milestones or is failure to thrive. 14. Behavior Identify any Infant/toddler behaviors known problems during the first 3 years of life. Comment or explain as needed. 15. Dental Page 4 of 5
5 Indicate yes, no, or unknown whether or not the child has ever seen the dentist. Enter date (if known) of last exam and timeframe from last visit to the dentist. Indicate and describe if child ever had oral surgery (extractions) or if there are dental problems. 16. Vision Indicate yes, no, or unknown if the child has any visual problems, the date and time frame from the last of visual exam. Describe any details of visual problems. Describe whether or not the child wears glasses or contact lenses. 17. Hearing Indicate yes, no, or unknown if the child has any hearing problems, and describe the details of hearing problems. Indicate whether or not the child has had a hearing test and the results. Indicate whether or not the child has tubes in his/her ears and/or has chronic hear infections. Indicate if the child wears hearing aids. REFERENCE(S)/ATTACHMENTS: None RELATED POLICIES: QM Progress Notes QM Core Assessment Access Authorization Request DISTRIBUTION: Enter X DL Name Enter X DL Name X Mental Health Staff X DHHS Human Resources Mental Health Treatment Center X Adult Contract Providers Children s Contract Providers X Alcohol and Drug Services Specific grant/specialty resource CONTACT INFORMATION: Quality Management Information QMInformation@saccounty.net Page 5 of 5
It is the policy of Sacramento County MHP that a Core Assessment be completed for all clients.
Title: County of Sacramento Department of Health and Human Services Division of Behavioral Health Services Policy and Procedure Policy Issuer (Unit/Program) Policy Number QM QM-10-26 Effective Date 07-01-2014
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