Sacramento County Electronic Utilization Review Tool EUR SPECIFIED FIELDS Client Name: Client ID: U.R. Date: Provider and Program: Reviewer Name: Review Period: Admission Date: A A1 B B1 CSI ADMISSION/ UPDATE CLIENT DATA Update CSI information Expectation that all CSI information is completed (race, ethnicity, preferred language, etc.). CLIENT RESOURCES/ COORDINATION OF CARE Family/Support person B2 Professional Contacts Include the name of one family member/support person, and their contact information (telephone number, etc.). Include the name, address, and phone number of PCP C MENTAL STATUS EXAM Date completed: C1 Completed Form must be completed in conjunction with all Core Assessments C2 Clinical Domains Expectation that all fields are completed, leaving no blanks without explanation. D DIAGNOSIS Diagnosis Date : D1 Included/Target Dx. Verify if client has an included primary
diagnosis. D2 Five Axis The full five Axis dx should be documented. D3 AOD Dx. If substance abuse/dependence was identified, diagnosis must be secondary to the primary mental health diagnosis Sacramento County Electronic Utilization Review Tool E CORE ASSESSMENT/ASSESSMENT Date completed: E1 Timely Completion Completed within 60 days of provider s start date; re-assessment done annually unless otherwise stipulated by program E2 E3 E4 Comprehensive Core Assessment Description of current presenting reasons Behavioral Health Hx. requirements. Expectation that all fields are completed, leaving no blank fields without explanation. Review the symptoms, behaviors, and level of functional impairment documented to support medical necessity. Include the onset of symptoms, severity and other significant changes affecting daily activities/functioning in important areas of life (history of presenting reasons). E5 Trauma Information Expect detailed information, including PTSD symptoms, particularly if trauma is impacting E6 Mental Health/ Psych Hx. functioning Detailed information describing inpatient and outpatient services, including use of traditional or alternative healing practices, and how it benefited the client s life. E7 Co-occurring Issues Detailed information regarding history and/or current substance abuse/use issues. If present, the Substance Abuse Assessment (CODA) must be completed. E8 Risk Assessment If identified past or present hx of risky behaviors, detailed measures that were taken to ensure the client s safety and well- being should be documented. A completed
Assessment Safety Plan should be documented. E9 Psychosocial Hx. Documentation of sufficient detail for family/ support, functional, housing-living situation, school functioning, etc., to provide a complete hx. If applicable, documentation of immigration/acculturation/family of origin history as well as cultural/spiritual background/information should be included E10 E11 Cultural Competence Sacramento County Electronic Utilization Review Tool as well. Client s cultural and language needs were explored, accommodated (i.e. the use of an interpreter) and documented? (Culture can include religion, ethnic/racial background, sexual orientation, gender, language, ability/disability, acculturation, etc.) Clinical Formulation Describe sufficient detail of client s mental health condition, establishing a sound clinical link between reasons for services and plan for wellness. F HEALTH QUESTIONNAIRE Date Completed: F1 F2 Initial and Annual Health Questionnaire Medical conditions/concerns Look for an initial/annual Health Questionnaire. Must be completed in full, if several unknown areas an explanation should be found in the progress notes. Must be completed within 60 days of the Provider Start Date. Look for a follow up progress note if client has any medical condition that needs attention from PCP. F3 Linkage to PCP If client is not yet linked to PCP, confirm efforts made to link the client to a PCP and, if warranted by medical condition, coordination of care documented in progress notes.
Sacramento County Electronic Utilization Review Tool G CLIENT PLAN/TREATMENT PLAN Date Completed: G1 G1 G2 Completion of initial Client Plan Completion of update/annual Client Plan Reasons for Service/Problem Initial client plan was completed, finalized, and signed/co-signed with 60 days of provider s start date. Annual client plan was completed, finalized, and signed/co-signed as required. The reasons for service/problem should reference those presenting problems identified in the assessment. G3 Goals Mental health treatment related goals to address the reasons for service/problem G4 Strengths & Barriers to Recovery and functional impairment. Plan should include strengths (positive assets) and barriers (difficulties or challenges) in objective section at minimum G5 Objective Objectives must be Specific, quantifiable and measurable, and refer back to the sx/bx/functional impairment described in G6 Substance abuse Objective reasons for service/problem. If the client plan includes a Substance Abuse related treatment objective, the Substance Abuse goal cannot be primary. (The objective addressing mental health must be primary.) G7 Interventions Look for detailed description of the responsibilities, actions and activities that client, staff and support person will contribute to achieve the client s objectives. Clinical interventions must be appropriate and reasonable to achieve the client s objectives. Case Management Brokerage services must be included as an G8 Cultural Competence intervention. If applicable, documentation of cultural/linguistic items should also be present in the client plan.
G9 Client s Signature Required for clients age 10 years old and older. If the signature is missing, there must be an explanation in the Service Plan sections. If the signature is absent for more than 60 days, there must be ongoing G10 Caregiver/LPS Conservator signature Sacramento County Electronic Utilization Review Tool explanations in the progress notes. If applicable, the caregiver/conservator signature is necessary. If the signature is missing, there must be an explanation in the Service Plan sections. If the signature is absent for more than 60 days, there must be ongoing explanations in the progress notes. H CODA / SUBSTANCE ABUSE ASSESSMENT Date Completed: H1 Completed CODA Assessment form must be completed if there are indicators of current/recent history of substance abuse/use. I LOCUS Date Completed: I1 Completed Form must be completed for authorization of services for all clients admitted at any of the MHSA full partnership programs, except for TWC. I2 Updated Form must be updated every six months when client s previous Locus indicated high intensity service need.
Sacramento County Electronic Utilization Review Tool J CANS (Child/Youth) Date Completed: J1 Completed Form must be completed at start of services, J2 J3 CANS and Client Treatment Plan CANS and Progress Notes every six months and at Discharge. Review the Client Plan, Clinical Formulation /Summary, and/or Plan Development Notes for any mention of the CANS items influencing the client s goals for treatment. Look for CANS information /reports to be used in sessions with youth and/or caregiver to discuss changes in behavior, symptoms, and progress toward goals. May also include changes to treatment plans based on CANS information. K INITIAL PSYCHIATRIC ASSESSMENT / PSYCHIATRIC ASSESSMENT Date Completed: K1 Completed Form must be completed at start of psychiatric services K2 Chief Complaint Presenting issues, relevant medical conditions, risk factors must be documented. K3 Psych Hx. Relevant medical conditions and past and current psychiatric history affecting the current mental health condition(s) must be documented. L PSYCHIATRIC MENTAL STATUS EXAM / MENTAL STATUS EXAM Date Completed: L1 Completed Form must be completed at start of psychiatric services and annually thereafter L2 All area completed Expectation that all fields are completed, leaving no blanks without explanation.
Sacramento County Electronic Utilization Review Tool M MEDICATION SERVICE PLAN Date Completed: M1 Completed All fields are completed at start of medication services and annually thereafter. M2 Client goals Required for all clients who are taking medications M3 Signatures Client and/or caregiver/conservator s, and Staff s signature are necessary. N VITALS N1 Completed Vital signs are recorded in the Vitals Entry of the chart. O ORDER CONNECT O1 Medications All medications are documented in Order Connect. P SCAN DOCUMENT SECTION/COLLATERAL INFORMATION P1 Consent to Tx. Required at start of service
P2 P3 Acknowledgement of Receipt Accounting of Disclosure Form Sacramento County Electronic Utilization Review Tool Required to be fully completed and signed by the client and clinician at start of services and annually thereafter, with all applicable boxes checked. Required, even if blank, and completed for unauthorized disclosures such as CPS. APS, State Audits, etc. P4 ROI s ROI s must be completed in full with signatures and no blank fields; updated P5 Collateral information P6 MHSA Full Partnership Info. P7 MEDICATION CONSENT annually. Look for collateral medical records and/or any old record scanned e.g., hospital D/C records and other provider collateral records. Look for completed Mode 60 form, KET, PAF and 3M forms. Look for updated medication consent for each medication prescribed Q Q1 CLINICAL PROGRESS NOTES Clinical Introductory Note Written at first visit, or soon after, includes a brief summary of reason for services/ medical necessity, description of symptoms, behaviors, functional impairment, relevant cultural explanation and proposed plan. Q2 Service Codes billed Documentation of service delivered must Q3 Q4 Q5 Progress notes content/medical necessity Progress notes content/key topics Progress notes content/intervention support service code that was claimed. Progress notes are unique and not cookie cutter, establishing medical necessity for the service by addressing client s sx/bx/functional impairment. Progress notes include a summary of the key topics of the service. The intervention is both appropriate to address the sx/bx/functional impairment and within the scope of practice of the
Sacramento County Electronic Utilization Review Tool Q6 Q7 Q8 Progress notes content/plan Progress notes reflecting Service Plan Cultural Competence practitioner. Progress notes contain a relevant follow up plan. Progress notes should be treatment goal oriented and reflect client s strengths and challenges. Client s cultural and language needs were explored, accommodated (i.e. the use of an interpreter) and documented Q9 Group Services Group notes must include the group s type, topic, goal, staff s intervention, client s participation and response, as well as a f/u plan. If two staff facilitated the group, each staff s role must be distinct/unique Q10 Coordination of Care services Q11 Excessive Billing Q12 Duplicative Services Q13 Non-Billable services Q14 Lockout Services and justified. Secure that progress notes indicate coordination of care (intra and inter agency) as well as evidence of clinical case conferencing within the agency as needed. Documentation should support the amount of time that is billed. Duplicative services are not billed Appropriate documentation of non-billable services, such as supervision, researching a topic, interpretation services, filing, faxing, educational services, transportation, etc. Appropriate documentation for services provided while the client was in a lockout situation, such as jail, juvenile hall, or psychiatric hospitalization R MEDICATION SERVICES PROGRESS NOTES R1 Service Codes billed Verify that each service code billed matches the service delivered. R2 Case consultation Look for detailed med support staff level of
consultation with MD note for medication refill or medication verbal order. R3 Group Session meds Look for group type, topic, goal, staff intervention, client participation and response as well as f/u plan. Also, if two staff facilitated the group, each staff role should be distinct/unique and justified. R4 Excessive Billing Billing for administrative type duties with no specific medication service function; watch for billing to capture time for no-shows with no service of benefit to the client Sacramento County Electronic Utilization Review Tool S GENERAL DOCUMENTATION S1 HIPAA Guidelines were adhered to (no breaches of confidentiality, i.e. other person s info in client s chart, etc.)?