History and Physical - Content1

What specific data must be included in the history and physical examination?

Organizations have the flexibility of determining the content of the history and physical based on the population served and the services provided. However, there are identified requirements for specific populations of individuals served such as Opioid Treatment Program patients, children and youth, intellectual and developmental disabilities, and if the organization is certified as a Behavioral Health Home. The organization is required to have a practitioner qualified by the scope of the practitioner's license participate in developing the data to be collected and the physical health screening process. Population groups that do have specific history and physical requirements are identified in the standards. These include CTS.02.01.07 and CTS.02.02.09 for Opioid Treatment Programs; CTS.02.02.01 for Behavioral Health Homes; CTS.02.03.03 for children and youth; and CTS.02.03.05 for Intellectual/Development Disabilities.
Last updated on April 11, 2016
Manual: Behavioral Health
Chapter: Care Treatment and Services CTS

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