Clinical Record Evaluation Tool- Detoxification (Providers)
ADDITIONAL REQUIREMENTS
# / Yes / No / DETOXIFICATION CLINICAL RECORD REQUIREMENTS / Comment / Regulation /A. / Does the clinical record include a medical evaluation no later than 24 hours after admission and during the course of active treatment as needed, a medical evaluation? / 70.110(d)(4) /
B. / Does the clinical record include evidence that daily monitoring occurred for each recipient by a physician, PA or ANP? / 70.110(d)(5) /
C. / If necessary, is there evidence that hourly monitoring (24hrs per day) of a recipient’s medication administration and progress took place? / 70.110(d)(6) /
D. / Were the services listed below performed by a nurse operating within their scope of practice?
· Monitoring, assessment, and management of intoxication
· Evaluation of a recipient’s withdrawal by applying CIWA-Ar or COWS / 70.110(d)(7)(B) /
E. / Were three of the following component services provided to the recipient at least once during the course of treatment?
Please circle the three components that were provided to the recipient:
· medication administration services;
· referrals to other behavioral, medical, social, or educational agencies, as needed;
· discharge or transfer planning;
· evaluation and treatment of symptoms of intoxication and withdrawal;
· comprehensive community support services;
· crisis or relapse prevention planning;
· individual daily assessment;*
· case management;
· management of a recipient's chronic disease, if medically necessary and clinically appropriate;
· urinalysis and breathalyzer testing, when specifically related to detoxification;
· development of coping skills in the recovery environment. / 70.110(e) /
F. / Was the detoxification service medically necessary and clinically appropriate in accordance with
· ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders;
· Diagnostic and Statistical Manual of Mental Disorders; and
· CIWA-Ar; or
· COWS? / 70.110(h) /
* If individual daily assessment is one on the component services used it must meet the following definition: “the ongoing daily process of collecting information regarding the recipient’s treatment needs, preferences, and desired outcomes” (70.110(i)).
Clinical Record Evaluation Tool- Detoxification (Providers) Page 1