ࡱ> S@ Ybjbj Us d>>>>>>>4r222h"33rU4h>:>:>:>:;X>@TTTTTTT$KWRYLU]>Bi;";BBU>>>:>:+_UMMMB>>:>>:TMBTMMM>>M>:4 2EMNuU0UMYHYMrr>>>>Y>M<A"AMA BAAAUUrrv!DlMrrv!Nursing Medication Management Reportable CodesCodesTimeDurationCodesTimeDuration FORMCHECKBOX 99361Medical Staffing  FORMTEXT        FORMTEXT       FORMCHECKBOX  Phone Contact  (C)   FORMTEXT       FORMTEXT       FORMCHECKBOX Case Mgt with TD Check  FORMTEXT        FORMTEXT       FORMCHECKBOX Phone Contact - (L) FORMTEXT       FORMTEXT       FORMCHECKBOX TD Check  FORMTEXT       FORMTEXT        FORMCHECKBOX Collateral Contact - (C)  FORMTEXT       FORMTEXT       FORMCHECKBOX Injection FORMTEXT       FORMTEXT        FORMCHECKBOX Collateral Contact - (L)  FORMTEXT       FORMTEXT       FORMCHECKBOX Rx supervision FORMTEXT       FORMTEXT        FORMCHECKBOX Tx Plan Update FORMTEXT       FORMTEXT       FORMCHECKBOX Rx Training/Support FORMTEXT       FORMTEXT       FORMCHECKBOX Tx Plan Review  FORMTEXT       FORMTEXT       FORMCHECKBOX Case Management  (C) FORMTEXT       FORMTEXT       FORMCHECKBOX Staffing FORMTEXT       FORMTEXT       FORMCHECKBOX Case Management  (L) FORMTEXT       FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMTEXT       FORMTEXT         FORMTEXT       Provide one selection for each category belowPlace of Service: FORMDROPDOWN Type of Contact: FORMDROPDOWN  Appointment Type: FORMDROPDOWN  EPSDT Ref: FORMDROPDOWN  Progress NotesDate: FORMTEXT      Time: FORMTEXT      Duration: FORMTEXT      (Time spent with client)T:  FORMTEXT      P:  FORMTEXT  Hhjlx   , . 0 : ŻwocoQc?"jh`CVCJUaJmHnHu#jha2%ha2%CJUaJjha2%CJUaJha2%CJaJhsehK|5CJaJ#j{h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJ hK|5 hK|5CJh`| hK|5CJ hK|CJhK|5CJaJh`| hK|5CJaJhsehUhse5CJhUhse5CJaJ hseCJ<Hjl-kd$$Ifl4F &0*v   &&&0    4 laf4p&&& $$Ifa$gdgx$If]^ $IfgdgxXYlx > j l $If^`$If]^gd`| $If]^Ffp$$If^a$gd`| $$If]^a$gd`| $If]^$$If^`a$gd`| : < > B D X Z \ f h j l n 趧~skse[eK[jCha2%ha2%CJUjha2%CJU ha2%CJhK|CJaJhx-hK|CJaJhsehK|5CJaJ#jh`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJ hK|CJ"jh`CVCJUaJmHnHu#jYha2%ha2%CJUaJha2%CJaJhF9hK|CJaJjha2%CJUaJ " F t  D zm $If]gd(3 $$Ifa$gdgx$If]^gdgx$If]^$If]^`gd|$If]^gdse$If]^gd|Ff $If^gd(3$If]^gd`|      " $ @ B D F t x z Ʒڊz෬h#jh`CVh`CVCJUaJj=ha2%ha2%CJUj ha2%ha2%CJU#j_ h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJhK|jha2%ha2%CJU ha2%CJ hK|CJjha2%CJUjh`CVCJUmHnHu&      2 4 6 @ B D F Z \ ^ h j l n p ݧ㷣wgj_ha2%ha2%CJU#jh`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJhK|jha2%ha2%CJU hK|CJjh`CVCJUmHnHuj'ha2%ha2%CJU ha2%CJjha2%CJUh`| hK|5h`| hK|5aJ#D l n $ d $$If]a$gdgxFf $Ifgd(3 $$Ifa$gdgx$If]^gdgx$If]^ $If]gd| $Ifgdgx$If]^Ff $If]gd(3   " $ H N P b d f z | ~ {k{[WhK|j5ha2%ha2%CJUjha2%ha2%CJU ha2%CJ h)6!hK|h)6!hK|5aJ hK|5aJhx-hK|5aJ#jKh`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJ hK|CJjh`CVCJUmHnHujha2%CJUjha2%ha2%CJU        , . 0 : < B J P R n p r t ¸¸|j`Y`Qh)6!hK|5 hK|5aJhx-hK|5aJ#jh`CVh`CVCJUaJ hK|CJj3ha2%ha2%CJUjh`CVCJUmHnHujha2%ha2%CJU ha2%CJjha2%CJU hK|CJh/(8hK|CJaJhsehK|CJaJjhsehK|CJUaJ#jIh`CVh`CVCJUaJ  > P t ,Jr$If]^$$If]a$gd|$$If]a$gdgx$If]^Ffd! $Ifgd(3 $$Ifa$gdgx$If]^gdgx$If]^ $Ifgd|  &(*,JL`bdnprtڤxm]jE$ha2%ha2%CJUh`| hK|CJaJ#j#h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJjha2%ha2%CJU hK|CJjh`CVCJUmHnHujha2%ha2%CJU ha2%CJjha2%CJUhx-hK|5hx-hK|5aJhK|!  $&(2468:VXZ\`啅uq_Z hK|5#jg+h`CVh`CVCJUaJhK|j&ha2%ha2%CJUj%ha2%ha2%CJU ha2%CJhx-hK|5#j1%h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJ hK|CJjh`CVCJUmHnHujha2%CJUj$ha2%ha2%CJU 68\(PxzFf0 $Ifgd| $Ifgdgx$If]^gdgx$If]^$$If]a$gd|$$If]^a$gd|Ff( $Ifgd(3 $$Ifa$gdgx`lr(*>@Bޝ毗}k}a[Kaj;-ha2%ha2%CJU ha2%CJjha2%CJU#j,h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJ hK|CJ#jQ,ha2%ha2%CJUaJh/(8hK|CJaJ"jh`CVCJUaJmHnHu#j+ha2%ha2%CJUaJha2%CJaJjha2%CJUaJ hK|5ho$hK|5BLNPRfhjtvxz|  Ʒ~n_~O_j3ha2%ha2%5Ujh`CV5UmHnHujc3ha2%ha2%5U ha2%5jha2%5Uho$hK|5 hK|5#j2h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJhK|j-ha2%ha2%CJU ha2%CJ hK|CJjha2%CJUjh`CVCJUmHnHuz@RzDFj $Ifgda2% $$Ifa$gd%UFf8 $Ifgd(3 $$Ifa$gdgx$If]^gdgx $Ifgdgx $$Ifa$gdR! $$Ifa$gdgx$If]^gd%U:<>@PRThjlvxz| 񹯩sa\ ha2%5#j:h`CVh`CVCJUaJj95ha2%ha2%CJU hK|CJjh`CVCJUmHnHuj4ha2%ha2%CJU ha2%CJjha2%CJUhx-hK|5#jO4h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJhK| hK|5jha2%5U!  246@BDFHdfhjvz|ʺ϶~t~dtTtt~jh`CVCJUmHnHujY<ha2%ha2%CJUjha2%CJU ha2%CJ hK|CJ#j;h`CVh`CVCJUaJhsehK|CJaJjhsehK|CJUaJhK|jo;ha2%ha2%5U ha2%5ho$hK|5jh`CV5UmHnHujha2%5Uj:ha2%ha2%5Uj68:<>  !dFfpE$If]^gdgx$If]^ $$Ifa$gd%U $$Ifa$gdgx$If]^gd%UFf$@ $Ifgd(3 $Ifgdgx$&(24:<>ɹϵɍϵ|rl\rl|j~Hh`CVh`CVCJU hpnCJjhpnCJU hpn5CJ hpnCJhpnjBha2%ha2%CJUho$hK|5 hK|5hsehK|CJaJhK|jE=ha2%ha2%CJU ha2%CJ hK|CJjh`CVCJUmHnHujha2%CJUj<ha2%ha2%CJU$>*PtxfQfff$ $If]^a$ $If]^$ $If]a$lkdG$$Ifl4  **  &0  4 laf4p &  $If$&(*PRnprt*,.8:<PRfﴮylyjRhpnCJUjh`CVCJUmHnHujQhpnCJUjhpnCJU hpn5CJ hpn5CJ hpnCJhpnjLh`CVh`CVCJUjJh`CVh`CVCJU hpn5CJjIh`CVh`CVCJU hpnCJjhpnCJU't`RH $If $If]ckdP$$Ifl4{**  04 laf4 $ $Ifa$ dFfkN $If] $If]^<Px $If $ $Ifa$fhjtvxNN NNN*N,N.N8N:NFNZN\NpNrNtN~NNNNNҷҪبқˑ~njh`CVCJUmHnHujUhpnCJU hpnCJjhpnCJUjTUhpnCJUUjThpnCJUjhThpnCJU hpn5CJ hpn5CJ hpnCJjh`CVCJUmHnHujhpnCJUjRhpnCJU) N) $If^kdR$$Ifl4G֞v : * ~ FTF  04 laf4    R:  FORMTEXT      BP: Sitting:  FORMTEXT      Standing:  FORMTEXT      WT:  FORMTEXT      HT:  FORMTEXT      AIMS:  FORMTEXT      Diagnosis CodeICD-9 (Axis I): FORMTEXT        FORMTEXT      ( Axis I required for billing. Write in ICD-9 Code and description.ICD-9 (Axis II): FORMTEXT      ICD-9 (Axis III): FORMTEXT      Axis IV: FORMTEXT      Axis V:  FORMCHECKBOX  GAF  FORMCHECKBOX  CGAS  FORMCHECKBOX  DC03 Current  FORMTEXT       Highest Past Year  FORMTEXT       (  FORMCHECKBOX  Change diagnosis in the record (  FORMCHECKBOX  Add Additional Diagnosis to the record __________________________________________________________________  Signature Title  Primary SecondaryPatient Name: FORMTEXT      Staff: FORMTEXT       FORMTEXT  Clinic: FORMTEXT      Patient ID No.: FORMTEXT      Service: FORMTEXT       CMH-544c 1/9/04 (electronic)Program: FORMTEXT      Protocol: FORMTEXT       CENTRAL WASHINGTON COMPREHENSIVE MENTAL HEALTH Mental Health Record of Service (Nursing Staff) NQ@QBQLQNQRQTQdQjQlQQQQQQQQQQQQQQ4R6RJRLRNRŻŮػŨ~najbhpnCJUjYbh`CVh`CVCJUjah`CVh`CVCJUjqah`CVh`CVCJUjhpnCJU hpnCJj_hpnCJUjhpnCJU hpnCJ hpn5CJ hhCJjh`CVCJUmHnHujhhCJUj9^hhCJU$QQQ(QPQuk]] $If] $If^kd^$$Ifl4F *f  0    4 laf4PQRQTQdQRuk]O$If]^ $If] $If^kdR`$$Ifl4F~ *f  ! 0    4 laf4NRXRZRRRRRRRRRRRRRRRRRRSS4S8SLSNSRSTSpSrStSSSSøëÉÉÉ~qiYqjZeh`CVh`CV5Uhnyhny5jhnyhny5U jhnyhny5hnyhny5CJjdh`CVh`CV5Uhnyhpn5jhnyhpn5U jhnyhpn5hnyhpn5CJ hpnCJjCchpnCJU hpnCJjhpnCJUjh`CVCJUmHnHu!RRSug$If]^kdc$$Ifl4F~ *f    !  0    4 laf4SSSSSSUUUUUU`````5u*&#$$d%d &d 'd +D/0$NO P Q gdgx ckde$$Ifl4**  04 laf4 SSSSSUUUUUUUUVVVVV&V(V*V,V.V0V8VVVVϽyohbh\TIbhk?Kh'/CJaJhk?KCJaJ hk?KCJ h'/CJ h'/5CJhk?KhfaCJH* hF@CJH* hpnCJH* hpnCJhgxCJ aJ h:5CJ hpnCJ hF95CJ hpn5CJh"+h"+5 h"+5#jh"+hwY5UmHnHuhF@hF@CJ aJ hF@CJ aJ hk?KCJ aJ ha2%CJ aJ hseCJ aJ hhCJUUUUUUUUUUUUUUUVVV*V,V P$If P6$gdF@ P6$5u*&#$$d%d &d 'd +D/0$NO P Q gdgx,V.V0VVVVWW@kdf$$Ifl  \T*0  4 la P$Ifgdk?K P$If P$IfVVVVVVW W WWWWW2W4WBWFWHWJW^W`WbWhWjWlW|W~WWWWWWWWWW񺴤ᝓuhējDf Dropdown3 Appointment Type Scheduled  Unscheduled No Show  Client Cancel Staff CancelDfYes/NoYes/NoYesNo$$If!vh5 5555555*#v #v#v#v#v#v*:V l48 P&&&&&&&&0  ,5 55555*4f4pP&&&&&&&&}kdL$$Ifl4  8ִ@ #`'* * P&&&&&&&&0      4 laf4pP&&&&&&&&$$If!vh5*#v*:V l4{05*/ /  / 4f4tDText3tDText2tDText4p$$If!vh55~ 5F5T5F55 #v#v~ #vF#vT#vF#v#v :V l4G0,55~ 5F5T5F55 /  / / / / / /  4f4vDText35vDText36vDText37vDText41vDText16vDText19vDText56vDText55$$If!vh5J5858555585b#vJ#v8#v#v#v8#vb:V l40,5J5855585b/  /  / /  / /  / /  / /  / / / / / / /  /  4f4vDText57~$IfK$L$l!vh5#v:Vl t05vDText49$$If!vh5f55#vf#v#v:V l4,0,5f55/ /  / /  / / /  4f4vDText50$$If!vh5f55#vf#v#v:V l40+,5f55/  /  / /  / / /  4f4vDText50+$$If!vh5f55#vf#v#v:V l40+,5f55/ /  / / /  / / /  4f4vDText52$$If!vh5f55 !#vf#v#v !:V l40+,5f55 !/ /  / /  / / /  4f4tDeCheck1tDeCheck1tDeCheck1vDText47vDText48+$$If!vh5f55 !#vf#v#v !:V l40+,5f55 !/ /  / / /  / /  /  4f4tDeCheck1tDeCheck1$$If!vh5*#v*:V l40,5*/ /  / 4f4.$$If!vh5555#v#v#v#v:V l0  ,,5555/  /  / /  / / / 4tD#Text5vDText92($$If!vh5555#v#v#v#v:V l0  ,5555/  / / / / / / 4tD#Text7tD#Text9 $$If!vh5555#v#v#v#v:V l0  ,5555/  /  / / / 4tD#Text8vD#Text10$$If!vh5555#v#v#v#v:V l0  5555/  /  / / 4vD#Text11$$If!vh555#v#v#v:V l40  +555/ / / 4f4vD#Text12$$If!vh555#v#v#v:V l40  +555/  / / 4f4$$If!vh5*#v*:Vls t06,5*@@@ NormalOJQJ_HmH sH tH >@> Heading 1$$@&a$CJ>@> Heading 2$$@&a$5L@L Heading 3$@&]^5CJR@R Heading 4$$@&]^a$5CJT@T Heading 5 $l@&]^`l5CJB@B Heading 6$$@&a$5CJR@R Heading 7$$@&]^a$5CJR@R Heading 8$$@&]^a$5CJB @B Heading 9 $$@&a$5CJDAD Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List NT@N Block Text$]^a$5CJ4@4 Header  !4 @4 Footer  !j@#j s Table Grid7:V0H2H >s Balloon TextCJOJQJ^JaJ  t$56<AJKQV_`rx#:Pfgy2FZ[mw%9MRds(<=Oey"#5Qeyz{|}~(:FXYZijpA`y<Mabcu] ^       d e s     4 = Q R S ] q r s @0( @0( @0( @0, @0 @0 @0 @0 @0 @0 @0 @0 @0@ @0@ @0@ @0@ @0@ @0@ @0@ @0@ @0@ @0@ @0D @0@ @0@ @0@ @0@ @0@ @0@ @ 0@ @0@ @0@ @0D @0@ @0@ @0@ @0@ @0@ @0@ @ 0@ @0@ @0@ @0D @0@ @0@ @0@ @0@ @0@ @0@ @ 0@ @0@ @0@ @0D @0@ @0@ @0@ @0@ @0@ @0@ @ 0@ @0@ @0@ @0D @0@ @ 0@ @0@ @0@ @0@ @0@ @0@ @0@ @0@ @0D @0@ @ 0@ @ 0@ @ 0@ @ 0@ @0@ @ 0@ @0@ @0@ @0D @0@ @ 0@ @ 0@ @ 0@ @ 0@ @0@ @0@ @0@ @0@ @0D @0 @ 0 @ 0 @ 0 @0 @0 @0 @0 @0 @0 @0@0P @0T @0P @0P @0P @0P @0P @0P @0P @0P @0T @0@0P @0T @0P @0P @0P @0P @0P @0P @0P @0T @0@ @0@ @0@ @0@ @0@ @0@ @0@ @0@ @0D @0P @0P @0P @0T @0P @0T @0P @0P @0P @0T `0P @0P @0P @0T `0P @0P @0P @0T `0P @0P @0P @0T @0@ @0D @0@0@0 @0(@0@0@0 @0 @0y@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0@0@0 @0 @0 @0 @0 @0@ @0@ @0@ @0@ @0D @0@ @0@ @0@ @0@ @0D @0P @0P @0P @0P @0T @0@0@0 @0 @0 @0 `0P @0P @0P @0T @@0(@0( @0, @0@0e8$56V_`rx#:Pgy2Fmw%Rds(<eQey{|(:FXYZijpA`y<Mabcu] ^   Q R q r s {0 {0{0- {0 {0 k{0H m {0 {0 {0C {0C {0C {0C {0C {0C {0{0C {0U {0U {0C {08 {0U {0{0{0{0C {0~ {0{0{0t {0{0C {0~ {0Oy0{0~ {0t {0C {0U {0t {0h)kOy0{0U {0~ {0C {0{0~ {0k{0N {0C {0U {0@(U{0dk{0U {0{0U{0=k{0N {0U Oy0{0C {0Oy0 {0 mOy0Oy0Oy0Oy0Oy0Oy0Oy0Oy0Oy0Oy0Oy0Oy0Oy0 Oy0 Oy0Oy0"Oy0"Oy0"Oy0"Oy0"Oy0"Oy0"Oy0Oy0$Oy0$Oy0$Oy0$Oy0$Oy0$Oy0$Oy0$Oy0Oy0&Oy0&Oy0&Oy0Oy0(Oy0(Oy0(Oy0Oy0*Oy0(Oy0(Oy0Oy0,Oy0,Oy0,Oy0Oy0.Oy0.Oy0.Oy0Oy00Oy0{0{0Oy02Oy02Oy02Oy02Oy02Oy02d0<Oy0dOy04dh<Oy0dOy06d<Oy0dOy08d9Oy0dOy0:d9Oy0d @a{0pY@  g8cccccccccccccccccf: `B fNOQNRSVWXY  "%.147:=@Dl D zj>t NXOZOOPQPQRSU,VWW(XXXYY !#$&-/0235689;<>?ABCEY `p!<HNR^dgw2>DFRX[kw%179EKRbs &(4:=Meqwy  #3=IOQ]ceqw(8FVp| -9?LX^eqw}MY_u & , I U [ f v s   = I O ] i o G$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFG$FFFFS$S$S$S$FTFTFTFFFFFtFtFFFFFFFG$G$G$FFG$G$FTFFTFTFTFTFTFT8@(  HB  C DB S  ?  t<Text58Text59Text74Text75Text60Text61Text76Text77Text62Text63Text78Text79Text64Text65Text80Text81Text66Text67Text82Text83Check5Text68Text69Text84Text85Text70Text71Text86Text87Text72Text73Text90Text88Text89Text91 Dropdown1 Dropdown2 Dropdown3Text35Text36Text37Text41Text16Text19Text56Text55Text57Text49Text50Text52Text47Text48Text5Text92Text7Text9Text8Text10Text11Text12=S3Gx&:t)fz>Rf) .Mf~N J t  > ^   !"#$%&'()*+,-./0123456789:;OeEY8L';x !Pdx9@_x`- \  P p FFu s & 8*urn:schemas-microsoft-com:office:smarttagsdate9*urn:schemas-microsoft-com:office:smarttagsplace 120049DayMonthYear<ORe2EFYw%89Ldfs'(;exy !=PQdexp -@L_ex}M`u - I \ s  = P ] p r s <ORe%)2EFYw%89Ldfs'(;exy !=PQdexp -@L_ex}*:M`u - I \ s  = P ] p r s 33333op !<ORevw2EFYjkw%89Labs'(;LMexy !23=PQdex78UVp -@L_ex}M`u - I \ u v        r s  " & = P ] p r s s Don SelfIH4`| B R! ( s 'hQo$!;~g)6!"%a2%x-'/3(3/(89f9;F@k?KMR%U`CVG_ eQf~ky=k>szwgxny|K|#g~ vfa:f8[*3G )i\JN"+F9&*?cfLP/f#*=gxpn'wYUbse$56<AJKQV_`rx#:Pfgy2FZ[mw%9MRds(<=Oey"#5Qeyz{|}~(:FXYZijpA`y<Mabcu] ^     d e s   4 = Q R S ] q r s  @ `q47``X PP P PPPPNUnknownGz Times New Roman5Symbol3& z Arial?Wingdings 3?Wingdings 29Garamond5& zaTahoma"qh}};f  !24dm m 3H)?4 Don SelfDon SelfOh+'0  8 D P \hpx ss Don Self on on psych-nurse.dot Don Selfse.1n Microsoft Word 10.0@@[@@ ՜.+,D՜.+,0 hp  CWCMHum   TitleP@3G_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_PreviousAdHocReviewCycleIDp0Mental Health Record of Service Medical 2-12-03Pyoung@cwcmh.orgord Pam Youngmh  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F`-Data Gp1TableYWordDocumentUSummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q