Discharge Template 1-19-11

INPATIENT SERVICES DISCHARGE TEMPLATE ALL FIELDS WITH * ARE REQUIRED Provider EDS/CMAP ID # (Medicaid 9-digit ID): _________________________________________________________________________________ Facility/Provider Name: _________________________________________________________ Contact # & Ext: _____________________________ Facility/Provider Service Location: Name of clinician who filled out this form: _____________________________________________________ Credentials/Title: __________________ Member Name: ____________________________________________________________________________________________________________ Medicaid/Consumer ID#: ____________________________ DOB: ____________________________ and/or SSN: _________________________

LEVEL OF CARE:  Inpatient

 Partial Hospitalization

 PRTF

 Adult Group Home

QUESTIONS: 1.

* Actual Discharge date (EX: 09/01/2010):

2.

*Behavioral Diagnoses (Primary is required) *Diagnosis Code: _______________ *Description_________________________________________________ *Diagnostic Category: _______________________________________________________________________

3.

Functional Assessment (Optional) CDC- HRQOL

CGAS

FAST

GAF

OMFAQ

SF12

OTHER _____________________________________

SF36

WHO DAS

ASSESSMENT SCORE _______________

4.

*Discharge Condition Compared to Admittance (please check appropriate box):

5.

 Improved  No Change  Worse  Unknown *Medication at Discharge with Dosage and Frequency (Narrative):

CURRENT RISKS (Key): 0 = None

1 = Mild or Mildly Incapacitating

2 = Moderate or Moderately Incapacitating

3 = Severe or Severely Incapacitating

N/A = Not

Assessed

Please circle one of the following for each question below based on Current Risks Key above: 6.

*Member’s risk to self?

0

1

2

3

N/A

Check all that apply: (*Required if Risk is Moderate or Severe)  Ideation  Intent 7.

 Plan

*Member’s risk to others?

0

 Means 1 2

3

 Current Serious Attempts

 Prior Serious Attempts

 Prior Gestures

 Prior Serious Attempts

 Prior Gestures

N/A

Check all that apply: (*Required if Risk is Moderate or Severe)  Ideation  Intent 8.

 Plan

 Means

 Current Serious Attempts

Current Impairments A. *Mood Disturbances (Depression or Mania)  0  1  2  3  N/A C. *Anxiety  0  1

 2

 3

B. *Weight Changes Associated with Behavioral Diagnosis  0  1  2  3  N/A For 2 or 3 rating: Weight  Gain  Loss  N/A  N/A Past 3 mos Lbs  N/A Current Wt _ Lbs Height _ Ft _In  N/A

 N/A

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9.

D. *Psychosis / Hallucinations / Delusions  0  1  2  3  N/A

E. *Medical / Physical Conditions  0  1  2  3

   F. *Thinking/Cognitive/Memory/Concentration Problems   0  1  2  3  N/A  

   G. *Substance Abuse / Dependence  0  1  2  3  N/A For 2 or 3 rating: Check all that apply  Alcohol Illegal  Drugs Prescription Drugs

H. *Impulsive/Reckless/Aggressive Behavior  0  1  2  3  N/A

I. *Job/School/Performance Problems  0  1  2  3  N/A

J. *Activities of Daily Living Problems  0  1  2  3  N/A

K. *Social Functioning/Relationships/Marital/Family Problems  0  1  2  3  N/A

L. *Impairments Related to Loss/Trauma  0  1  2  3  N/A

M. *Legal  0  1  2  3  N/A For 1, 2 or 3 rating: Check all that apply  Juv Jus  Probation  Parole  Other Court

 N/A

*Type of Discharge Planned  Unpl a n n e d

10. *Discharge plan in place? 

No

Yes

11. *Actual Level of Care/Service Discharge To (primary)  Community Support Team  PHP  RTC

 Outpatient  Targeted Case Management  Inpatient

 Group Home  Halfway House  Day Services

 Community Support  Day Treatment

 Alternative

 Respite  Specialty Children’s Programs

 Assertive Community Treatment

 NCMC Only Ambulatory Detox

 CSU

 Foster Care  In-Home & Family Services  Placement

Services  PRTF  Residential Child Care Other

 IOP/SOP

 23 Hour

 Facility Based Crisis

 Subacute 

 Intensive In-Home

 MST

 NCMC Only Medically Supervised ADATC

 NCMC Only Non-Hospital Med Detox.  NCMC Only SA Med Monitored Resi  NCMC Only SA Non Med Resi Over 21  Opioid Treatment 12. *PCP Notified?  Yes

 No

 Psychosocial Rehab

 SACOT

 N/A

13. *Actual Discharge Residence (Primary)  AW-AWOL  CP-CCP/High Meadow  C-Correction Facility

 FH-Foster Home  HM-Home

 IL-Independent Living  J-Juvenile Detention  6-Nursing Home/SNF/Assisted Living  RT-RTC/Group Home  SH-State Hospital  FC-Therapeutic Foster Care  3-Transfer to Alt. Psych or Rehab Facility  2-Transfer to medical  UK-Unknown

 Other

14. *Is member being discharged from RTC, GH, PRTF?  Yes

 No

15. *If yes, reason for RTC, GH, or PRTF Discharge?  Age 18/signed self out

 Aged out

 AWOL

 Court Ordered / Mandated

 Medically Compromised  Needs higher level of care

 Fire Setting Risk

 Parent/Caretaker removed child

 Psychiatrically decompensation  Ready for lower level of care

 Run away history  Sexually appropriate

 Too aggressive / assault  Too Low functioning 16. Additional RTC, GH, or PRTF Discharge Information (Narrative)

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17. *Person to Contact for Follow Up: _____________________________________________________________________________ *Relationship: __________________________________________ *Phone #:

________________________________________

18. *Does the discharge plan involve Member, Guardian and/or Parent participation?  Yes

 No

 Unknown

19. *What CT BHP Services are needed?  ICM

 Peer Services

 ICM & Peer Services

 None

18. *Aftercare Behavioral Health Provider  Not Arranged

 Arranged Do Not Know  Member Refused

20. *Aftercare Prescribing Physician  Not Arranged

 Arranged Do Not Know  Member Refused

21. *Add one more behavioral health appointment?  Yes

 No

22. *Follow up Exemption  Yes

 No

23. *Follow Up Type?  Routine

 Intensive

 No Further

24. *Date of First Follow up Contact (MMDDYYYY):

_______________________________________________________

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