Outpatient reviews

THESE REQUIREMENTS WERE REMOVED EFFECTIVE 7/1/2008

Members are expected to get the initial authorization for outpatients services. However, after the initial sessions are completed, a direct care provider needs to complete a mental health or substance abuse assessment, depending on which services the patient requires. For subsequent reviews, use the follow-up report to track treatment progress.

Jump to:
Mental health assessment
Substance abuse assessment
Follow-up report


Mental health assessment

1. Practitioner information:
2. Initial date:
3. Chief complaint & history of present illness:
4. Member’s psychiatric and substance abuse history:
5. Family’s psychiatric and substance abuse history:
6. Other pertinent family, social, school, employment, legal information:
7. Medical illness history:
8. Medications/allergies:
9. Risk factors:
10. Mental status:
11. Symptoms of Axis I diagnosis:
12. Diagnosis:
13. Treatment plan:
14. Referral options:

Substance abuse assessment

1. Practitioner information:
   
2. Caller:
   
3. Initial date seen:
4. Referral source:
5. Present illness:
6. Chief complaint & history of present illness:
7. Vitals:
8. Detox symptoms:
9. Current health:
10. Pregnant:
11. Legal/driving history:
12. Family history:
13. Age of first use of alcohol or drugs:
14. Drug of choice:
15. Use of other drugs?
16. Alcohol type preferred?
17. Frequency/amount of use:
18. Using alcohol or drugs?
19. Tolerance changed?
20. What are the reasons the member gives for using substances?
21. Longest period of sobriety in the past two years?
22. How long has substance abuse been problematic?
23. Date of last use:
24. Has member ever harmed self or considered self-harm?
25. If yes, please explain:
26. Diagnosis treatment plan:
27. Recommendation:
28. Result:

Follow-up report

1. Practitioner information:
2. Current treatment plan:
3. Type of review:
4. Current symptoms:
5. Progress, or lack of, relating to treatment plan:
6. Communication with PCP:
7. Medications:
8. Current risk factors:
   
9. Reason for continued sessions:
10. Diagnosis:
11. Treatment plan:
12. Is there a need for a psychiatric evaluation?
13. Is there a need for a substance abuse evaluation?
14. Is a referral to the primary care physician indicated?