NYSCRI Child Comprehensive Assessment v2 (NYCCA2)

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Form Details

• A. Form Properties
  1. Form Title: NYSCRI Child Comprehensive Assessment v2
  2. Start from an Existing Form - Yes, if there is a previous assessment signed and locked.
  3. Copyrighted Form - No
  4. Billable Progress Note - No
  5. Have multiple versions open at same time - No
  6. Open Blank on new version - No
• Required Fields - Yes
• Lookup Tables - None
• Pre-Fill Logic - Yes
  1. Organization Name will prefill from Setup †’ Program/Billing Defaults †’ Company Info Tab.
  2. Program Name will prefill from the Program the patient is enrolled in.
  3. Active Medications on Psychiatric Tab will prefill from ePrescribing.
  4. Diagnosis Tab will prefill from any form with Diagnosis.
• Fill to Logic - Yes
  1. NYSCRI Adult Comprehensive Assessment v2 Form will fill to NYSCRI Adult Comprehensive Assessment Update Form.
  2. Diagnosis Tab will fill to any form with a Diagnosis.
  3. Identified needs will fill to the NYSCRI Initial Individualized Action Plan / NYSCRI Individualized Action Plan Review.
• Signatures
  1. Individual Served Signature
     • Credential: Patient
     • Manually type in name.
  2. Guardian Signature
     • Credential: None
     • Manually type in name.
  3. Provider Signature
     • Credential required to sign: Provider.
     • Title will fill title entered in user setup.
     • Route To functionality is available.
  4. Supervisor Signature
     • Credential required to sign: Supervisor.
     • Title will fill title entered in user setup.
     • Defaults to NA checked.
     • Signature required if NA is unchecked.
     • Route To functionality is available.
  5. Psychiatrist Signature
     • Credential required to sign: Psychiatrist.
     • Title will fill title entered in user setup (see eCR University - Users).
     • Defaults to NA checked.
     • Signature required if NA is unchecked.
     • Route To functionality is available.

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Pres. Concerns Tab

1. Organization Name and Program Name will prefill from Program/Billing Defaults.
2. Enter the reason for referral.
3. Enter the family/guardian description of the problem.
4. Check the individual’s current living situation.
5. Check the individual’s residential care/treatment facility.

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Family Tab (1 of 2)

1. Enter the family composition for the individual.
2. Family Relationships: Required fields:
   • Comment on parent-child, sibling-individual and parent marital or couple’s relationship(s).
   • Sibling-individual relationships
     • Grey out- Selecting ‘No Siblings’ will grey out text field.
   • Parent marital or couple’s relationships
     • Grey out- Selecting ‘not applicable’ will grey out text field.

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Family Tab (2 of 2)

1. Enter any other significant family information.
2. Select any other family concerns, indicate the family member and describe the concern.
   • Grey out- Selecting ‘No’ response to any line items will grey out the text field on that line.

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Custody Tab

1. Select and enter the custody information of the individual.
   • Grey out - Selecting Yes, will grey out the text fields.

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Social Tab

1. Enter the individual’s social support/issues.
   • All fields required.
2. Enter the individual’s cultural/ethnic information and select their race.
   • All fields required.

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Sexual Tab

1. Select and describe the individual’s sexual preference and activity (if applicable).
   • Grey out:
     • Selecting NA to ‘What is the individual’s sexual preference’ will grey out options.
     • Selecting No to ‘Is Individual currently sexually active’ will grey out text field.
2. Enter any developmental history and developmental disability (if applicable).
   • Grey out:
     • Selecting No will grey out the text field.

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Education Tab

1. Enter and select the details of the individual’s education.
   • Grey out:
     • Regular education classroom - Selecting Yes will grey out Education Classification selections.
     • Test Results - Selecting No test results reported will grey out the text field.
     • Attendance - Selecting Not a Problem will grey out the text field.

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Legal (LIA, LSA) Tab

1. Enter additional information regarding the patient’s education.
   • All questions required.
   • Grey out - If Denied selected for retentions; expulsions; and Barriers, the corresponding text field will grey out.
2. Enter the individual€™s legal status and legal involvement history.
   • All questions required.
   • Grey out - Selecting None Reported will grey out the entire section.
   • If Yes response to ‘history will legal system or involvement with CPS’, Legal Involvement Assessment will open.
     • Form will not save if Addendum not completed.
   • If yes response to legal guardian, Legal Status Addendum will open.
     • Form will not save if Addendum not completed.

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Employment (EA, MSO) Tab

1. Select and describe the individual’s current employment status if applicable.
   • Grey out - Selecting ‘Not Pertinent’ will grey out the section.
2. Enter and select the individual’s employment history.
   • Selecting Yes to ‘Does the individual want to find employment’ will open the Employment/Educational Assessment Addendum.
3. Select if the individual has someone in their family or a significant other in the military.
   • If yes, complete and attach the Military Significant Other form.

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Treatment (SUA) Tab

1. Select if the individual reported currently uses or has a history of substances/addictive behaviors.
   • If yes to any of the substances/addictive behaviors, complete and attach the Substance Use Addendum.
2. Enter any treatment services history within the past 5 years (if applicable).
3. Enter details regarding treatment at an outpatient facility.
   • Grey out - Selecting NA will grey out options.
4. Enter details regarding treatment at an inpatient facility.
   • Grey out - Selecting NA will grey out options.
5. Enter details regarding treatment in the ER/detox.
   • Grey out - Selecting NA will grey out options.

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Psychiatric Tab

1. Enter additional information regarding the individual’s treatment history.
2. Describe the individual’s illness history from age on onset.
3. Enter reported side-effects, medication compliance, and comments on past medications.
   • Selecting Surescripts will bring user to the eprescribe (see eCR University - ePrescribe).

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Trauma (RA) Tab

1. Select and describe the individual’s trauma history (if applicable).
   • Grey out - Selecting None Reported will grey out text field.
2. Select if there were any past attempts by the individual to harm themselves or others.
   • Selecting Self or Other will launch the Risk Assessment Addendum.
3. Select and describe any past alerts that may contribute to the patient being a risk to themselves or others.
   • Grey out - Selecting No to any of the questions in this section will grey out the text field.

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Past Risk Tab

1. Elaborate any other alerts that may indicate a tendency towards violence.
   • Grey out- Selecting No will grey out text field.
2. Select and describe if the individual has current or past issues with anger management.
   • Grey out- Selecting No will grey out text field.
3. Select and describe individual’s history of violence.
   • Grey out- Selecting No will grey out text field.

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Mental Status (MSE, RA) Tab

1. Enter a mental health evaluation or complete the Mental Status Evaluation addendum.
   • Selecting Refer to attached Mental Status Examination will launch the Mental Status Exam and grey out the Mental Status exam text field.
2. If providing a mental health status narrative, select options to answer the current risk related questions.
   • Grey out - Selecting denied any danger to self/others will grey out the section.
   • Selecting any ‘Danger To’ items will launch the Risk Assessment Addendum.
3. Assessed Needs - Functional Domains
   • Select any applicable options regarding challenges, problems in daily living, barriers, obstacles that are assessed needs and add comments or check the box to complete a functional assessment.
   • Fill To - Any need identified as Current Need Area (CN) will fill to the Needs section on the Prioritized Needs tab of this form.

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Addictive Tab

1. Select any applicable options regarding addictive behaviors and add comments.
2. Select any applicable options regarding behavior management and add comments.

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Social Tab

Select any applicable options regarding family and social support and add comments.

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Mental Tab

Select any applicable options regarding mental health and illness management and add comments.

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Physical Tab

1. Select any applicable options regarding mental health and illness management and add comments.
2. Select any applicable options regarding physical health and add comments.

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Risk Tab

1. Select any applicable options regarding risk/safety and add comments.
2. Select any applicable options regarding legal problems and any other area or need not mentioned and add comments.

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Life Goals Tab

1. Enter any life goals, strengths, abilities, and barriers.
2. Describe any service preferences.

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Screening Tab

1. Select if any evidenced-based screening tool(s), for either mental health or substance use, utilized and specify if yes.
   • Grey out - Selecting No will grey out text field.
2. Complete the Clinical Summary by checking and entering information and enter the Interpretive Summary.

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Axis Tab

1. Add/edit the diagnosis
   • Prefill - Diagnosis will prefill from the most recent completed form and fill to subsequent forms that contain the diagnosis field.
     • A primary diagnosis must be selected to save/lock the form.

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Prioritized Tab

1. Select any further evaluations needed.
2.  Assessed needs will populate in the table.
   • Assessed needs prefills from Current Needs (CN) identified earlier in the assessment.
3. Prioritize needs
   • Select Status: Active, Individual Declined, Deferred, Referred Out
     • Active needs will prefill to the Needs section of the NYSCRI Initial Individualized Action Plan Review and the NYSCRI Individualized Action Plan Review.

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Individual Tab

1. Explain why individual declined to work on needs are and/or list rationale(s) for why need area(s) is deferred/referred out below.
2. Enter the indicated service recommendations.
3. Enter the child/guardian/family response to recommendations.
4. Individual Served Signature
   • Credential: Patient
   • Manually type in name.
5. Guardian Signature
   • Credential: None
   • Manually type in name.

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Signature Tab

Signature Credentials (see eCR University - Credentials)

1. Provider Signature
   • Credential required to sign: Provider.
   • Title will fill title entered in user setup.
   • Route To functionality is available.
2. Supervisor Signature
   • Credential required to sign: Supervisor.
   • Title will fill title entered in user setup.
   • Defaults to NA checked.
   • Signature required if NA is unchecked.
   • Route To functionality is available.
3. Psychiatrist Signature
   • Credential required to sign: Psychiatrist.
   • Title will fill title entered in user setup.
   • Defaults to NA checked.
   • Signature required if NA is unchecked.
   • Route To functionality is available.

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