Inpatient Treatment Report Form Page 2
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2PATIENT’S NAME: ______________________________ PATIENT’S ID#_______________
PAGE TWO OF TWO
None
Dose
Freq. Usually adherent?
Current Psychotropic Medications:
Discharge Plan:
Expected D/C Date if known: ___/___/___ Estimated return to work date ___/___/___
Yes
No
Planned D/C Level of Care:
Outpatient
Inpatient
23 hr
CSU
RTC
Partial
Yes
No
IOP/SOP
Group Home
Halfway House
Other: ________________________
Planned D/C Residence:
Home (
Alone or
w/Others)
Yes
No
Nursing Home/SNF/Asst. Living
RTC/Group Home/Halfway House
Shelter
Correctional Facility
Foster Care
Respite
State Hosp.
Residential Placemt.
Yes
No
Juvenile Detention
Transfer to Medical
Transfer to Alternate Psych. Facility
Substance Use/Abuse:
No
Yes
Unknown If yes, please complete below.
Other_______________________________________________________________
Length
Date Last
Discharge Information: (to be included upon discharge)
Substance
Curr. Use
Amount
Freq.
Used
Actual Discharge Date: ____/____/____
Primary Discharge Diagnosis: _____________________________________________
Discharge GAF: _____ Discharge Condition:
Improved
No Change
Worse
Treatment involved the following (check all that apply):
Adverse Incident
Child Protection
EAP
Family
Legal System
OP Provider
Other Support Systems
PCP
None
Other: ___________________________
Note: Any adverse incidents must be reported immediately to ValueOptions.
Discharge plans in place?
Yes
No
Withdrawal Symptoms: Check all that apply.
None
Type of Discharge:
Planned or
AMA
PCP Notified
Yes
No
Nausea
Sweating
Tremors
Past DTs
Actual Discharge Level of Care:
Outpatient
Inpatient
23 hr
CSU
Vomiting
Agitation
Blackouts
Current Seizures
RTC
Partial
IOP/SOP
Group Home
Halfway House
Cramping
Hallucinations
Current DTs
Past Seizures
Other ______________________________________________________________
Vitals (if Detox or Relevant): BP:____ Temp:____ Pulse:____Resp:____BAL:____
Actual Discharge Residence:
Home (
Alone or
w/Others)
UDS:
Yes
No Date:_______ Outcome:
Pending
Negative
Positive
Nursing Home/SNF/Asst. Living
RTC/Group Home/Halfway House
Shelter
Correctional Facility
Foster Care
Respite
State Hosp.
Residential Placemt.
If positive, for what?______________________________________________________
Juvenile Detention
Transfer to Medical
Transfer to Alternate Psych. Facility
Longest period of sobriety:
<6 mo.
6 mo.-2yrs
2+ yrs
None
Unknown
Other: ______________________________________________________________
Relapse Date: ____/____/____
ASAM Dimensions:
Member/Family Member Name for Follow Up:
1. Intoxicated/WD Potential
Lo
Med
Hi 4. Readiness to Change
Lo
Med
Hi
_____________________________________________________________________
2. Biomedical Conditions
Lo
Med
Hi 5. Relapse Potential
Lo
Med
Hi
Relationship: __________________________________________________________
3. Emot/Beh/Cog Conditions
Lo
Med
Hi 6. Recovery Environment
Lo
Med
Hi
Phone #:______________________________________
Do not know
Treatment Request:
Admit Date: ____/____/____
After Care Behavioral Health Provider:
Not arranged
Do not know
(Note well: Each level of care, ECT &/or Psych Testing requires separate precertification)
After Care Provider Name:________________________________________________
Is family/couples therapy indicated?
Yes
No If yes, date of appt. ___/___/___
After Care Provider Tel. #: ________________________________________________
Involuntary
Court Ordered
Fixed Length Program (Specify length: _______)
Scheduled Appointment Date: ____/____/____
Frequency of program = ___________ per ___________________________________
Type of Appointment:
Mental Health
Substance Abuse
Med Mgmt.
Reason for Continued Stay:
Remains symptomatic
Conduct family therapy
Prescribing Physician:
Not arranged
Do not know
Stabilize medications
Has not achieved treatment goals
Finalize dischg. plan
Prescribing Physician Name: ______________________________________________
Other ______________________________________________________________
Prescribing Physician Tel #:_______________________________________________
Barriers to Discharge:
Discharge treatment setting not available
Transportation
Prescriber:
PCP
Psychiatrist
Other Prescriber Type
Legal Mandate
Adequate Housing/Residence
Lack of Community Support
Scheduled Appointment Date: ____/____/____
Treatment Non-Compliance
Other _____________________________________
Baseline Functioning:
Holds Job
Asymptomatic
Manages Meds/Med Compliant
______________________________________________________________________
Functions Independently/ADLs Satisfactory
Abstinent
Other_____________
Signature of Person Completing This Form
Date
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