"Public Health Case Record Checklist" - California

Public Health Case Record Checklist is a legal document that was released by the California Department of Health Care Services - a government authority operating within California.

Form Details:

  • The latest edition currently provided by the California Department of Health Care Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Public Health Case Record Checklist" - California

491 times
Rate (4.3 / 5) 34 votes
Public Health Case Record Checklist
Client:
DOB:
M-C ID:
Case Mgr:
Location:
Dates of
Service:
Review the case file to determine if the LGA identified the client’s need(s). The client’s need must meet at
least one of following criteria/requirements to qualify for the Public Health target population:
Medi-Cal eligible high-risk persons identified as having a need for public health case management services
including the following individuals:
Women, infants, children and young adults to age 21
Persons with HIV/AIDS
Persons with reportable communicable diseases
Pregnant women
Persons who are technology dependent
Persons who are medically fragile
Persons with multiple diagnoses
Identify at least one of the service components used to assist the client in meeting their need(s):
Assessment – must include the following as relevant to each individual:
____
Medical/mental condition
____
Training needs for community living
____
Vocational/educational needs
____
Physical needs, such as food & clothing
____
Social/emotional status
____
Housing/physical environment
____
Familial/social support system
Comprehensive Service Plan – must include the following:
____
Actions required to meet identified service needs
____
Community programs, persons, and/or agencies to which the beneficiary will be referred
____
Description of the nature, frequency, and duration of the activities and specific strategies to achieve
service outcomes
Linkages, Consultations, and Referrals
Follow-up, required within 30 days, to include the following:
____
Beneficiary received referral services
____
Services met the beneficiary’s needs
Assistance in Accessing Services – must include one of the following:
____
Arranging appointments and/or transportation to medical, social, educational, and other services
____
Arranging translation services to facilitate communication between the beneficiary and the case
manager, or the beneficiary and other agencies or service providers(s)
Crisis Assistance Planning – must include one of the following:
____
Evaluates, coordinates, and arranges immediate service or treatment needed to avoid, eliminate, or
reduce a crisis situation
Periodic Review
____
Completed at least every six months
____
Conducted by the case manager in consultation with the beneficiary
____
Approved by the case manager’s supervisor
Public Health Case Record Checklist
Client:
DOB:
M-C ID:
Case Mgr:
Location:
Dates of
Service:
Review the case file to determine if the LGA identified the client’s need(s). The client’s need must meet at
least one of following criteria/requirements to qualify for the Public Health target population:
Medi-Cal eligible high-risk persons identified as having a need for public health case management services
including the following individuals:
Women, infants, children and young adults to age 21
Persons with HIV/AIDS
Persons with reportable communicable diseases
Pregnant women
Persons who are technology dependent
Persons who are medically fragile
Persons with multiple diagnoses
Identify at least one of the service components used to assist the client in meeting their need(s):
Assessment – must include the following as relevant to each individual:
____
Medical/mental condition
____
Training needs for community living
____
Vocational/educational needs
____
Physical needs, such as food & clothing
____
Social/emotional status
____
Housing/physical environment
____
Familial/social support system
Comprehensive Service Plan – must include the following:
____
Actions required to meet identified service needs
____
Community programs, persons, and/or agencies to which the beneficiary will be referred
____
Description of the nature, frequency, and duration of the activities and specific strategies to achieve
service outcomes
Linkages, Consultations, and Referrals
Follow-up, required within 30 days, to include the following:
____
Beneficiary received referral services
____
Services met the beneficiary’s needs
Assistance in Accessing Services – must include one of the following:
____
Arranging appointments and/or transportation to medical, social, educational, and other services
____
Arranging translation services to facilitate communication between the beneficiary and the case
manager, or the beneficiary and other agencies or service providers(s)
Crisis Assistance Planning – must include one of the following:
____
Evaluates, coordinates, and arranges immediate service or treatment needed to avoid, eliminate, or
reduce a crisis situation
Periodic Review
____
Completed at least every six months
____
Conducted by the case manager in consultation with the beneficiary
____
Approved by the case manager’s supervisor
Outpatient Clinics Case Record Checklist
Client:
DOB:
M-C ID:
Case Mgr:
Location:
Dates of
Service:
Review the case file to determine if the LGA identified the client’s need(s). The client’s need must meet at
least one of following criteria/requirements to qualify for the Outpatient Clinics target population:
Medi-Cal eligible persons who are in need of outpatient clinic medical services and who need case management
services in connection with their treatment because they are unable to access or appropriately use services,
including individuals who:
Have demonstrated noncompliance with their medical regimen
Are unable to understand medical directions because of language or other comprehension barriers
Have no community support system to assist in follow-up care at home
Require services from multiple health care/social service providers in order to maximize health
outcomes
Identify at least one of the service components used to assist the client in meeting their need(s):
Assessment – must include the following as relevant to each individual:
____
Medical/mental condition
____
Training needs for community living
____
Vocational/educational needs
____
Physical needs, such as food & clothing
____
Social/emotional status
____
Housing/physical environment
____
Familial/social support system
Comprehensive Service Plan – must include the following:
____
Actions required to meet identified service needs
____
Community programs, persons, and/or agencies to which the beneficiary will be referred
____
Description of the nature, frequency, and duration of the activities and specific strategies to achieve
service outcomes
Linkages, Consultations, and Referrals
Follow-up, required within 30 days, to include the following:
____
Beneficiary received referral services
____
Services met the beneficiary’s needs
Assistance in Accessing Services – must include one of the following:
____
Arranging appointments and/or transportation to medical, social, educational, and other services
____
Arranging translation services to facilitate communication between the beneficiary and the case
manager, or the beneficiary and other agencies or service providers(s)
Crisis Assistance Planning – must include one of the following:
____
Evaluates, coordinates, and arranges immediate service or treatment needed to avoid, eliminate, or
reduce a crisis situation
Periodic Review
____
Completed at least every six months
____
Conducted by the case manager in consultation with the beneficiary
____
Approved by the case manager’s supervisor
Public Guardian Case Record Checklist
Client:
DOB:
M-C ID:
Case Mgr:
Location:
Dates of
Service:
Review the case file to determine if the LGA identified the client’s need(s). The client's need must meet at
least one of the following criteria/requirements for the Public Guardian target population:
Medi-Cal eligible individuals who are 18 years or older:
who have exhibited an inability to handle personal, medical, or other affairs; or
who are under conservatorship of a person and/or estate or a representative payee.
Identify at least one of the service components used to assist the client in meeting his or her need(s):
Assessment – must include the following as relevant to each individual:
____
Medical/mental condition
____
Training needs for community living
____
Vocational/educational needs
____
Physical needs, such as food & clothing
____
Social/emotional status
____
Housing/physical environment
____
Familial/social support system
Comprehensive Service Plan – must include the following:
____
Actions required to meet identified service needs
____
Community programs, persons, and/or agencies to which the beneficiary will be referred
____
Description of the nature, frequency, and duration of the activities and specific strategies to achieve
service outcomes
Linkages, Consultations, and Referrals
Follow-up, required within 30 days, to include the following:
____
Beneficiary received referral services
____
Services met the beneficiary’s needs
Assistance in Accessing Services – must include one of the following:
____
Arranging appointments and/or transportation to medical, social, educational, and other services
____
Arranging translation services to facilitate communication between the beneficiary and the case
manager, or the beneficiary and other agencies or service providers(s)
Crisis Assistance Planning – must include one of the following:
____
Evaluates, coordinates, and arranges immediate service or treatment needed to avoid, eliminate, or
reduce a crisis situation
Periodic Review
____
Completed at least every six months
____
Conducted by the case manager in consultation with the beneficiary
____
Approved by the case manager’s supervisor
Aging and Adult Services/Linkages Case Record Checklist
Client:
DOB:
M-C ID:
Case Mgr:
Location:
Dates of
Service:
1. Review the case file to determine if the LGA identified the client’s need(s). The client's need must meet at
least one of the following criteria/requirements for the Linkages target population:
Medi-Cal eligible individuals who are 18 years or older, in frail health, and in need of assistance to access
services in order to keep them from becoming institutionalized.
2. Identify at least one of the service components used to assist the client in meeting his or her need(s):
Assessment – must include the following as relevant to each individual:
____
Medical/mental condition
____
Training needs for community living
____
Vocational/educational needs
____
Physical needs, such as food & clothing
____
Social/emotional status
____
Housing/physical environment
____
Familial/social support system
Comprehensive Service Plan – must include the following:
____
Actions required to meet identified service needs
____
Community programs, persons, and/or agencies to which the beneficiary will be referred
____
Description of the nature, frequency, and duration of the activities and specific strategies to achieve service
outcomes
Linkages, Consultations, and Referrals
Follow-up, required within 30 days, to include the following:
____
Beneficiary received referral services
____
Services met the beneficiary’s needs
Assistance in Accessing Services – must include one of the following:
____
Arranging appointments and/or transportation to medical, social, educational, and other services
____
Arranging translation services to facilitate communication between the beneficiary and the case manager,
or the beneficiary and other agencies or service providers(s)
Crisis Assistance Planning – must include one of the following:
____
Evaluates, coordinates, and arranges immediate service or treatment needed to avoid, eliminate, or reduce
a crisis situation
Periodic Review– must include the following:
____
Completed at least every six months
____
Conducted by the case manager in consultation with the beneficiary
____
Approved by the case manager’s supervisor
Adult Probation Case Record Checklist
Client:
DOB:
M-C ID:
Case Mgr:
Location:
Dates of
Service:
1. Review the case file to determine if the LGA identified the client’s need(s). The client's need must
meet at least one of the following criteria/requirements for the Adult Probation target population:
Medi-Cal eligible persons who are 18 years of age or older on probation who have a medical and/or
mental condition and are in need of assistance in accessing and coordination of medical, social,
and other services.
2. Identify at least one of the service components used to assist the client in meeting his or her need(s):
Assessment – must include the following as relevant to each individual:
____
Medical/mental condition
____
Training needs for community living
____
Vocational/educational needs
____
Physical needs, such as food & clothing
____
Social/emotional status
____
Housing/physical environment
____
Familial/social support system
Comprehensive Service Plan – must include the following:
____
Actions required to meet identified service needs
____
Community programs, persons, and/or agencies to which the beneficiary will be referred
____
Description of the nature, frequency, and duration of the activities and specific strategies to achieve
service outcomes
Linkages, Consultations, and Referrals
Follow-up, required within 30 days, to include the following:
____
Beneficiary received referral services
____
Services met the beneficiary’s needs
Assistance in Accessing Services – must include one of the following:
____
Arranging appointments and/or transportation to medical, social, educational, and other services
____
Arranging translation services to facilitate communication between the beneficiary and the case
manager, or the beneficiary and other agencies or service providers(s)
Crisis Assistance Planning – must include one of the following:
____
Evaluates, coordinates, and arranges immediate service or treatment needed to avoid, eliminate, or
reduce a crisis situation
Periodic Review– must include the following:
____
Completed at least every six months
____
Conducted by the case manager in consultation with the beneficiary
____
Approved by the case manager’s supervisor
Page of 7