4.9. SR 02-04-2019 - Laserfiche WebLink

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Instructions for completing the LOCUS Recording Form Date of Assessment The date the LOCUS assessment was completed. Date of Birth Month/Day/Year (MM/DD/YYYY) Gender Male or Female Recipient PMI or Social Security number PMI number is preferred over the social security number. Diagnosis Primary (Write in the full diagnostic name of the primary diagnosis or use the ICD code). Provider Name, NPI and Service Type NPI number and the name of the organization completing the LOCUS and what type of service is being provided by the staff completing the LOCUS assessment. Actual Level of Care What is the actual Level of Care the recipient is receiving? Write the actual name of the level (i.e. Medically Monitored Non -Residential). It may not necessarily be the same as the `Level of Care Recommendation' if a variance is being made. Service/Program Referred to Write the current program(s) recipient is in or what program(s) recipient has been referred to (example: ARMHS, Day Treatment, Case Management, Psychiatry, housing programs, etc.). Please keep in mind that there may be multiple services used to reach an individual's resource intensity needs. Reason for Variance (if applicable) 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. Clinical justification also needs to be documented in more detail as a separate document from the recording form. 4 In the dimension being evaluated please check which rating was given. On the line following the rating please indicate the letter(s) of the criteria that was used to determine the score. This information can be located in the AMHD LOCUS Questionnaire Booklet or in the training manual. Composite Score Add up the score from each dimension to determine the composite score. Level of Care Recommendation From the score and use of the decision tree, what is the Level of Care recommended. Write the actual name of the level (i.e. Medically Monitored Non -Residential) NOTE: the Level of Care recommendation maybe different from the composite score if Independent Criteria is indicated that requires admission to a Level 5 or Level 6 service. It may also be different if clinical judgment is used in determining that a different level of care is more appropriate than what the completed LOCUS assessment recommends. Signature spaces Signature spaces are located at the bottom of the page on the LOCUS Recording Form. If a Mental Health (Rehab) Professional is completing the LOCUS assessment, there does not need to be a signature by a clinical supervisor. 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.