The Comprehensive Clinical Assessment must include the following elements:
A. a chronological general health and behavioral health history (includes both mental health andsubstance abuse) of the recipient's symptoms, treatment, treatment response and attitudes abouttreatment over time, emphasizing factors that have contributed to or inhibited previous recoveryefforts;
B. biological, psychological, familial, social, developmental and environmental dimensions andidentified strengths and weaknesses in each area;
C. a description of the presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions; and current medications
D. a strengths/problem summary which addresses risk of harm, functional status, co-morbidity, recovery environment, and treatment and recovery history;
E. diagnoses on all five axes of DSM-IV;F. evidence of an interdisciplinary team progress note that documents the teams review and discussion of the assessment;
G. a recommendation regarding target population eligibility; andH. evidence of recipient participation including families, or when applicable, guardians or other caregivers
This assessment will be signed and dated by the MD, DO, PA, NP, licensed psychologist and will serve as the initial order for services included in the PCP. Upon completion, the PCP will be sent to the LME for administrative review and authorization of services under the purview of the LME.
For additional services added after the development of the initial PCP, the order requirement for each service is included in the service definition.