Vitals Checks in Withdrawal Management (BHIN 25-003)

In programs providing withdrawal management (detoxification), DHCS regulations and the Alcohol and Other Drug (AOD) certification standards require ongoing physiological monitoring of clients in early phases of admission. These monitoring requirements are intended to promote safety, early detection of medical complications, and compliance with licensing and certification rules.

Requirements for conducting and documenting vitals checks can be found in the following documents:

1. BHIN 21-001 Exhibit A, which defines monitoring requirements for detoxification settings.
2. The AOD Certification Standards (per BHIN 25-003), which define requirements for withdrawal management services in certified, and certified + licensed programs.
3. DHCS Form 6045 (Detoxification Observation – Vital Signs Check Log), which specifies the data elements and timeliness of documentation for vital signs.

CalMHSA has obtained confirmation from DHCS that using the “Vitals Flowsheet” screen in SmartCare contains the required elements specified in the references above, including verification of which staff entered the vitals check information. While the Vitals Flowsheet cannot be signed or initialed by the staff entering the data, SmartCare captures the user information and timestamp when the data is saved. CalMHSA also recommends using the locking function, which adds something similar to a signature at the bottom of the flowsheet.

CalMHSA is creating a new flowsheet called “Detox Observation – Physical Check”. This includes the following fields, which were based on DHCS Form 6045:

1. Date (standard field on all flow sheets) – this field automatically populates to today
2. Time (standard field on all flow sheets) – this field automatically populates to now
3. Program (standard field on all flow sheets) – this field is required for CDAG purposes
4. Location (location of the client) – this field is also used for Safety Checks and uses Global Code Category “XLocationType”
5. Respiration – this field is used to document whether the client is breathing or not (Yes/No)
6. Appearance – this field is an open text field
7. Behavioral – this field is also used for Safety Checks and is an open text field.
8. Activity – this field is also used for Safety Checks and uses Global Code Category “XActivityType”

See also:

CalMHSA will be posting Knowledge Base articles targeted to end users shortly. Links to these articles will be added below.