Form DHS-6249-ENG "Locus Recording Form" - Minnesota

What Is Form DHS-6249-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS-6249-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-6249-ENG "Locus Recording Form" - Minnesota

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*DHS-6249-ENG*
DHS-6249-ENG
6-16
LOCUS Recording Form
DATE OF ASSESSMENT
DIAGNOSIS
RECIPIENT DATE OF BIRTH
RECIPIENT GENDER
RECIPIENT PMI or SOCIAL SECURITY NUMBER
Male
Female
PROVIDER NAME
PROVIDER NPI
SERVICE TYPE
ACTUAL LEVEL OF CARE PROVIDED
SERVICE(S) RECIPIENT IS RECEIVING OR REFERRED TO
REASON FOR VARIANCE (if applicable)
I. Risk of Harm
IV-B. Recovery Environment – Level of support
1. Minimal
1. Highly Supportive
2. Low
2. Supportive
3. Moderate
3. Limited Support
4. Serious
4. Minimal Support
5. Extreme
5. No Support
II. Functional Status
V. Treatment and Recovery History
1. Minimal
1. Full Response
2. Mild
2. Significant Response
3. Moderate
3. Moderate or Equivocal Response
4. Serious
4. Poor Response
5. Severe
5. Negligible Response
III. Co-Morbidity
VI. Engagement
1. None
1. Optimal
2. Minor
2. Positive
3. Significant
3. Limited
4. Major
4. Minimal
5. Severe
5. Unengaged
COMPOSITE SCORE
IV-A. Recovery Environment – Level of Stress
1. Low
2. Mildly
LEVEL OF CARE RECOMMENDATION
3. Moderately
4. Highly
5. Extremely
NAME AND CREDENTIALS OF WHO COMPLETED
SIGNATURE
DATE
NAME OF CLINICAL SUPERVISOR (MH PROFESSIONAL)
SIGNATURE
DATE
As a mental health provider in the State of Minnesota, Deerfield Behavioral Health, Inc. is granting you permission to scan this completed
LOCUS Recording Form, where the dimensional scores, criteria, composite score and level of care recommendation have been documented,
into your electronic medical record.
*DHS-6249-ENG*
DHS-6249-ENG
6-16
LOCUS Recording Form
DATE OF ASSESSMENT
DIAGNOSIS
RECIPIENT DATE OF BIRTH
RECIPIENT GENDER
RECIPIENT PMI or SOCIAL SECURITY NUMBER
Male
Female
PROVIDER NAME
PROVIDER NPI
SERVICE TYPE
ACTUAL LEVEL OF CARE PROVIDED
SERVICE(S) RECIPIENT IS RECEIVING OR REFERRED TO
REASON FOR VARIANCE (if applicable)
I. Risk of Harm
IV-B. Recovery Environment – Level of support
1. Minimal
1. Highly Supportive
2. Low
2. Supportive
3. Moderate
3. Limited Support
4. Serious
4. Minimal Support
5. Extreme
5. No Support
II. Functional Status
V. Treatment and Recovery History
1. Minimal
1. Full Response
2. Mild
2. Significant Response
3. Moderate
3. Moderate or Equivocal Response
4. Serious
4. Poor Response
5. Severe
5. Negligible Response
III. Co-Morbidity
VI. Engagement
1. None
1. Optimal
2. Minor
2. Positive
3. Significant
3. Limited
4. Major
4. Minimal
5. Severe
5. Unengaged
COMPOSITE SCORE
IV-A. Recovery Environment – Level of Stress
1. Low
2. Mildly
LEVEL OF CARE RECOMMENDATION
3. Moderately
4. Highly
5. Extremely
NAME AND CREDENTIALS OF WHO COMPLETED
SIGNATURE
DATE
NAME OF CLINICAL SUPERVISOR (MH PROFESSIONAL)
SIGNATURE
DATE
As a mental health provider in the State of Minnesota, Deerfield Behavioral Health, Inc. is granting you permission to scan this completed
LOCUS Recording Form, where the dimensional scores, criteria, composite score and level of care recommendation have been documented,
into your electronic medical record.
Instructions for completing the
LOCUS Recording Form
Date of Assessment
Reason for Variance (if applicable)
The date the LOCUS assessment was completed.
If the service provided is at a different level of care from
the level of care recommendation, provide the brief
clinical justification as to why the variance was made.
Date of Birth
Clinical justification also needs to be documented in
Month/Day/Year (MM/DD/YYYY)
more detail as a separate document from the recording
form.
Gender
 In the dimension being evaluated please check
Male or Female
which rating was given. On the line following the
rating please indicate the letter(s) of the criteria that
Recipient PMI or Social Security number
was used to determine the score. This information can
be located in the AMHD LOCUS Questionnaire
PMI number is preferred over the social security
Booklet or in the training manual.
number.
Composite Score
Diagnosis
Add up the score from each dimension to determine
Primary (Write in the full diagnostic name of the
the composite score.
primary diagnosis or use the ICD code).
Level of Care Recommendation
Provider Name, NPI and Service Type
From the score and use of the decision tree, what is the
NPI number and the name of the organization
Level of Care recommended. Write the actual name of
completing the LOCUS and what type of service is
the level (i.e. Medically Monitored Non-Residential)
being provided by the staff completing the LOCUS
assessment.
NOTE: the Level of Care recommendation
may be different from the composite score if
Independent Criteria is indicated that requires
Actual Level of Care
admission to a Level 5 or Level 6 service. It may
What is the actual Level of Care the recipient is
also be different if clinical judgment is used in
receiving? Write the actual name of the level (i.e.
determining that a different level of care is more
Medically Monitored Non-Residential). It may
appropriate than what the completed LOCUS
not necessarily be the same as the ‘Level of Care
assessment recommends.
Recommendation’ if a variance is being made.
Signature spaces
Service/Program Referred to
Signature spaces are located at the bottom of the page
Write the current program(s) recipient is in or what
on the LOCUS Recording Form. If a Mental Health
program(s) recipient has been referred to (example:
(Rehab) Professional is completing the LOCUS
ARMHS, Day Treatment, Case Management,
assessment, there does not need to be a signature by a
Psychiatry, housing programs, etc.). Please keep in mind
clinical supervisor.
that there may be multiple services used to reach an
individual’s resource intensity needs.
As a mental health provider in the State of Minnesota, Deerfield Behavioral Health, Inc. is granting you permission to scan this completed
LOCUS Recording Form, where the dimensional scores, criteria, composite score and level of care recommendation have been documented,
into your electronic medical record.
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