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Preview - Ohio Behavioral Discharge Form

 

Ohio Behavioral Health

 

Integrated ODMH/ODADAS Discharge Form

 

 

 

Unique Provider Number:

 

Episode Number:

Name (first/last):

 

Paying Board:

Unique Client ID:

 

Date of Birth (mm/dd/yyyy):

Last Date of Service:

 

Discharge Date:

Discharge Reason

Successful Completion/Graduate

Assessment & evaluation only, successfully completed, no further services recommended

Assessment & evaluation only, successfully completed, client rejected recommendations

Left on own, against staff advice with SATISFACTORY Progress

Left on own, against staff advice with UNSATISFACTORY Progress

Involuntarily discharged due to non-participation

Involuntarily discharged due to violation of rules

Referred to another program or service with SATISFACTORY Progress

Referred to another program or service with UNSATISFACTORY Progress

Incarcerated due to Offense Committed while in Treatment with SATISFACTORY Progress

Incarcerated due to Offense Committed while in Treatment with UNSATISFACTORY Progress

Incarcerated due to Old Warrant/Charge from before Treatment with SATISFACTORY Progress

Incarcerated due to Old Warrant/Charge from before Treatment with UNSATISFACTORY Progress

Transferred to Another Facility for Health Reasons

Death

Client Moved

Needed Services Not Available

Other

 

 

 

 

 

 

Education Type – Choose if K-12 Selected:

 

 

Primary Income/Support (Select One)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did client choose another provider due to

 

 

religious preference?

 

 

 

Not Enrolled

 

Wages/Salary

 

 

 

 

 

 

 

 

Yes

No

 

 

 

Not SBH (Client doesn’t have an IEP)

 

Family/Relative

 

Highest Educational Level Completed

 

 

SBH (Client has an IEP )

 

Public Assistance

 

 

 

 

 

< 1st Grade

 

10th Grade

 

Employment Status (Choose One)

 

 

Retirement/Pension

 

1st Grade

 

11th Grade

 

Full Time

 

Disability

 

2nd Grade

 

12th Grade

 

Part Time

 

Other

 

3rd Grade

 

Tech School

 

Sheltered

 

Unknown

 

4th Grade

 

Some College

 

Unemployed, but actively looking for work

 

None

 

5th Grade

 

2 Yr Coll Degree

 

Unknown

 

Living Arrangements (Choose One)

 

 

6th Grade

 

4 Yr Coll Degree

 

Not in Labor Force (Choose One Below)

 

Independent living (own home)

 

7th Grade

 

Grad Degree

 

Homemaker

 

Homeless

 

8th Grade

 

Unknown

 

Student

 

Others’ Home

 

9th Grade

 

 

 

 

Volunteer

 

Residential Care / Group Home / ACF

 

 

 

 

Retired

 

Child Residential Treatment Center

 

Educational Enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pre-School

 

Voc/Job Training

 

Disabled

 

Respite Care

 

K-12th Grade

College

 

Inmate

 

Foster Care

 

GED Classes

 

Not Enrolled

 

Engaged in Residential/Hospitalization

 

Crisis Care

 

Other: Literacy,

Unknown

 

Other

 

Temporary Housing

Adult Basic Ed, etc

 

 

 

 

 

 

Community Residence

 

 

 

 

 

 

 

 

 

 

 

 

Living Arrangements (continued)

 

 

Drug of Choice (Continued)

 

 

ODMH: BIOMARKERS

 

 

 

 

 

 

 

 

Nursing Facility

 

 

Non-prescription Methadone

 

 

 

 

 

 

 

 

 

Source of Height/Weight Information

 

 

Licensed MR Facility

 

 

Other Opiates and Synthetics

 

-Reported

 

State MH/MR Institution

 

 

PCP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital

 

 

 

Other Hallucinogens

 

 

 

 

 

 

 

 

 

 

 

 

 

Height and Weight

 

 

Correctional Facility

 

 

Methamphetamines

 

 

 

 

 

Height (feet and inches)

 

Other

 

 

 

Other Amphetamines

 

 

|

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

Other Stimulants

 

 

 

 

 

Weight (lbs)

 

 

 

 

 

 

Benzodiazepines

 

 

|

 

 

 

 

Global Assessment of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

|

 

Functioning

 

 

Other Non-Barbiturate Tranquilizers

 

Physical Health Conditions

 

 

Diagnosis Type (Choose One)

 

 

Barbiturates

 

 

 

Does client report/provide evidence of any of the

 

DSM IV

ICD9

 

 

Other Non-Barb. Sedatives/Hypnotics

 

following conditions in past year?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diabetes

 

 

 

Primary Diagnosis Code:

 

 

Inhalants

 

 

 

 

 

 

 

 

 

 

 

Over-the-Counter Medications

 

High Cholesterol

 

 

 

 

 

 

Nicotine

 

 

 

 

Cardiovascular Disease (heart attack, stroke)

 

Secondary Diagnosis Code:

 

 

Other Medications

 

 

 

High blood pressure

 

 

 

 

 

 

Unknown

 

 

 

Cancer

 

 

 

 

 

 

 

 

Frequency of Use

 

 

 

Kidney Disease/Failure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 X Past Week

 

Bowel Obstruction (eg, constipation)

 

Tertiary Diagnosis Code:

 

 

 

 

 

 

 

 

 

 

 

 

2 X in Past Mo

6 X Past Week

 

Respiratory Disease (eg, COPD)

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Populations (Select all that Apply)

 

 

Route of Administration

 

 

 

Health Care Utilization

 

 

SMD/SED

 

 

Oral

 

Injection

 

How frequently (in days) has the client used the

 

Alcohol/Other Drug Abuse

 

 

Smoking

 

Other

 

following since admission or last update?

 

 

 

 

 

 

 

 

 

 

Forensic Status

 

 

Inhalation

Unknown

 

 

 

 

 

 

 

 

 

 

 

Hospital Admissions

 

 

 

 

 

 

 

 

 

 

 

|

 

 

Developmentally Disabled

 

 

 

 

Age of First Use – First

 

 

 

 

 

 

 

 

 

 

Deaf/Hard of Hearing

 

|

 

Intoxication

 

 

 

 

 

Emergency Room Visits/Admits

 

 

 

 

 

 

 

 

 

 

Blind/Sight Impaired

 

 

Primary AOD Code:

 

 

|

 

(psychiatric or physical health)

 

 

 

 

 

 

 

 

 

Physically Disabled

 

 

 

 

Number of Arrests past 30 days

 

 

 

Outpatient Primary Care Visits

 

Sexual Abuse Victim

 

|

 

(AOD NOM)

|

 

(physical health)

 

Domestic Violence Victim/Witness

 

 

Primary Reimbursement (Select One)

 

 

 

 

Dental Visits

 

Child of Alcohol/Drug Abuser

 

 

Self-Pay

 

 

 

|

 

 

 

 

 

 

 

 

 

 

 

HIV/AIDS

 

 

Blue Cross/Blue Shield

 

 

 

Evidence Based Practices

 

 

Suicidal

 

 

 

Medicare

 

 

 

 

Did the client receive any of the following EBPs

 

Language Barriers/English 2ND Lang.

 

 

Medicaid

 

 

 

 

since admission or last update?

 

Hepatitis C

 

 

Other Government Support

 

Adult Practices

 

 

Transgendered

 

 

Worker’s Compensation

 

฀ Supportive Housing

 

In Custody/Child Welfare

 

 

Other Private Health Insurance

 

฀ Supported Employment

 

Multiple Service System Involvement

 

 

No Charge

 

 

 

฀ Assertive Community Treatment (ACT)

 

 

 

 

Other Payment Source

 

 

 

 

 

 

Early Childhood: At Risk for SED

 

 

 

 

 

฀ Family Psycho-Education

 

 

Sexual Offender

 

 

 

 

฀ IDDT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequency of attendance at self-help

 

 

 

 

 

Bisexual/Gay/Lesbian

 

 

programs in the 30 days prior to discharge

 

 

฀ WMR/Illness Self-Management

 

 

 

 

 

 

 

 

 

 

Military Family

 

 

No attendance in past month

 

฀ Medication Management

 

Drug of Choice (Primary Choice)

 

 

1-3 X in past mo.

4-7 X in past mo.

 

Child & Adolescent Practices

 

 

Alcohol

 

 

 

8-15 X in past mo.

16-30 X in past mo.

 

Therapeutic Foster Care

 

Cocaine/Crack

 

 

Some but unknown

Unknown

 

Multi-Systemic Therapy (MST)

 

 

 

 

 

 

Functional Family Therapy

 

Marijuana/Hashish

 

 

Does the client use tobacco products?

 

 

 

Heroin

 

 

 

Yes

No

Don’t Know

 

Intensive Home-based Therapy (IBHT)

 

Drug of Choice (Secondary)

 

 

Drug of Choice (Tertiary)

 

 

 

 

 

 

 

 

Alcohol

 

 

 

Alcohol

 

 

 

 

Cocaine/Crack

 

 

Cocaine/Crack

 

 

Marijuana/Hashish

 

 

Marijuana/Hashish

 

 

Heroin

 

 

 

Heroin

 

 

 

 

Non-prescription Methadone

 

Non-prescription Methadone

 

Other Opiates and Synthetics

 

Other Opiates and Synthetics

 

PCP

 

 

 

PCP

 

 

 

 

Other Hallucinogens

 

 

Other Hallucinogens

 

 

Methamphetamines

 

 

Methamphetamines

 

 

Other Amphetamines

 

 

Other Amphetamines

 

 

Other Stimulants

 

 

Other Stimulants

 

 

Benzodiazepines

 

 

Benzodiazepines

 

 

Other Non-Barbiturate Tranquilizers

 

Other Non-Barbiturate Tranquilizers

 

Barbiturates

 

 

Barbiturates

 

 

Other Non-Barb. Sedatives/Hypnotics

 

Other Non-Barb. Sedatives/Hypnotics

 

Inhalants

 

 

 

Inhalants

 

 

 

 

Over-the-Counter Medications

 

Over-the-Counter Medications

 

Nicotine

 

 

 

Nicotine

 

 

 

 

Other Medications

 

 

Other Medications

 

 

Unknown

 

 

Unknown

 

 

None

 

 

 

None

 

 

 

Frequency of Use

 

Frequency of Use

 

 

No use Past Mo

1 3 X Past Week

 

No use Past Mo

1 3 X Past Week

 

1 2 X in Past Mo

3 6 X Past Week

 

1 2 X in Past Mo

3 6 X Past Week

 

Daily

 

Unknown

 

Daily

 

 

Unknown

Route of Administration

 

Route of Administration

 

 

Oral

 

Injection

 

Oral

 

 

Injection

 

Smoking

 

Other

 

Smoking

 

 

Other

 

Inhalation

 

Unknown

 

Inhalation

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

Age of First Use – First

 

 

 

Age of First Use – First

|

 

Intoxication

 

|

 

Intoxication

 

 

 

 

 

 

 

 

 

Secondary AOD Code

 

 

Tertiary AOD Code

 

 

 

 

 

 

 

 

 

 

 

 

Document Properties

Fact Name Details
Form Title Ohio Behavioral Health Integrated ODMH/ODADAS Discharge Form
Governing Laws Ohio Revised Code Sections 5119.22 and 5119.23
Provider Information Includes Unique Provider Number and Episode Number.
Client Identification Requires Name, Unique Client ID, and Date of Birth.
Discharge Reasons Multiple options, including Successful Completion and Involuntary Discharge.
Living Arrangements Options include Independent Living, Homeless, and Residential Care.
Health Conditions Captures physical health conditions and associated diagnosis codes.
Substance Use Information Records primary and secondary drug of choice, frequency of use.
Evidence-Based Practices Documents any EBPs received since admission or last update.

Documents used along the form

The Ohio Behavioral Discharge form is a crucial document used in the discharge process for individuals receiving behavioral health services. Alongside this form, several other documents are commonly utilized to ensure a comprehensive understanding of the client's treatment and ongoing needs. Below is a list of five such documents, each serving a specific purpose in the discharge process.

  • Client Treatment Plan: This document outlines the goals and objectives established for the client during their treatment. It includes interventions, timelines, and expected outcomes, providing a roadmap for the client’s care.
  • Progress Notes: These notes detail the client's progress throughout their treatment. They typically include observations from sessions, changes in behavior, and responses to interventions, helping to inform the discharge decision.
  • Motorcycle Bill of Sale: This document is essential for transferring ownership of a motorcycle in California. It includes necessary details such as the vehicle identification number (VIN) and sale price, ensuring a smooth transaction. For reference, you can find a blank form at documentonline.org/blank-california-motorcycle-bill-of-sale.
  • Referral Form: If a client is being referred to another service or program, this form is used to document the referral details. It includes information about the receiving provider and the specific services recommended for the client.
  • Aftercare Plan: This plan outlines the steps a client should take after discharge to maintain their progress. It may include follow-up appointments, support groups, and resources for continued care.
  • Consent for Release of Information: This document allows the sharing of the client’s treatment information with other providers or agencies. It is essential for coordinating care and ensuring that all parties involved have access to relevant information.

Each of these documents plays a vital role in ensuring that clients receive appropriate care and support after their discharge from behavioral health services. Proper documentation and communication are key to facilitating a smooth transition for clients as they move forward in their recovery journey.

Guidelines on Filling in Ohio Behavioral Discharge

Once you have gathered all necessary information, you can begin filling out the Ohio Behavioral Discharge form. This form is essential for documenting the details of a client's discharge from behavioral health services. Ensure that you have all relevant information on hand to complete each section accurately.

  1. Start by entering the Unique Provider Number and Episode Number at the top of the form.
  2. Fill in the Name of the client, including both first and last names.
  3. Indicate the Paying Board and the Unique Client ID.
  4. Provide the Date of Birth in the format mm/dd/yyyy.
  5. Enter the Last Date of Service and the Discharge Date.
  6. Select the appropriate Discharge Reason from the provided options by marking the corresponding checkbox.
  7. Choose the Education Type if applicable, especially if K-12 is selected.
  8. Identify the Primary Income/Support by selecting one of the options available.
  9. Answer whether the client chose another provider due to religious preference by selecting Yes or No.
  10. Complete the Highest Educational Level Completed section by selecting the appropriate grade or degree.
  11. Choose the Employment Status from the provided options.
  12. Indicate the Living Arrangements by selecting one of the options available.
  13. Fill out the Drug of Choice section, specifying the primary substance used.
  14. Provide the Height and Weight of the client.
  15. Complete the Physical Health Conditions section by selecting any relevant diagnoses.
  16. Document the Health Care Utilization details, including hospital admissions and outpatient visits.
  17. Fill out the Evidence Based Practices section to indicate if the client received any specific treatments.
  18. Provide information about the Drug of Choice for secondary and tertiary options as needed.
  19. Finally, review all entries for accuracy before submitting the form.

Common mistakes

Filling out the Ohio Behavioral Discharge form can be straightforward, but many people make common mistakes that can lead to complications. One frequent error is failing to provide accurate personal information. This includes the client’s name, date of birth, and unique client ID. If these details are incorrect, it may cause delays in processing and can affect the client's access to future services. Always double-check this information before submitting the form.

Another mistake is neglecting to select the appropriate discharge reason. The form includes various options, such as “Successful Completion” or “Involuntarily discharged due to non-participation.” Choosing the wrong reason can lead to misunderstandings about the client's status and needs. It’s essential to select the option that best reflects the client’s situation to ensure they receive the appropriate follow-up care.

People often overlook the section regarding the client’s educational background and employment status. This information is vital for understanding the client’s support system and can influence future treatment plans. Missing or incorrect entries in these sections can lead to gaps in care. Make sure to provide complete and accurate details about the client’s education and employment situation.

Lastly, individuals sometimes skip over the health conditions and medication sections. These areas are crucial for a comprehensive understanding of the client’s physical and mental health. Failing to report existing health issues or current medications can hinder effective treatment. It’s important to provide as much detail as possible in these sections to ensure the client receives the best care moving forward.

FAQ

  1. What is the purpose of the Ohio Behavioral Discharge form?

    The Ohio Behavioral Discharge form is designed to document the discharge of clients from behavioral health services. It captures essential information about the client's treatment episode, including the reason for discharge, client demographics, and any relevant health conditions. This information is vital for ensuring continuity of care and for reporting purposes.

  2. What information is required on the form?

    The form requires several pieces of information, including:

    • Unique Provider Number
    • Episode Number
    • Client's Name (first and last)
    • Unique Client ID
    • Date of Birth
    • Last Date of Service
    • Discharge Date
    • Discharge Reason

    Additional details regarding the client's educational background, employment status, living arrangements, and health conditions may also be required.

  3. What are the discharge reasons listed on the form?

    The form includes various discharge reasons, such as:

    • Successful Completion/Graduate
    • Involuntarily discharged due to non-participation
    • Left on own, against staff advice
    • Referred to another program or service
    • Incarcerated due to an offense committed while in treatment
    • Client moved
    • Death
    • Other specified reasons

    Each reason provides insight into the client's journey and outcomes during treatment.

  4. How does the form handle client confidentiality?

    The Ohio Behavioral Discharge form is subject to confidentiality regulations. Personal information must be handled with care to protect the client's privacy. Only authorized personnel should have access to the completed forms, and they should be stored securely in compliance with applicable laws.

  5. Can the form be used for clients with special populations?

    Yes, the form accommodates clients from special populations. It includes sections to identify clients who may be developmentally disabled, deaf or hard of hearing, victims of domestic violence, and more. This information is crucial for tailoring future services to meet their unique needs.

  6. What happens if a client is involuntarily discharged?

    If a client is involuntarily discharged, it is important to document the reason clearly on the form. This may include non-participation or violation of rules. The discharge process should follow established protocols to ensure the client is informed and that any necessary referrals are made.

  7. Is there a specific process for submitting the form?

    After completing the Ohio Behavioral Discharge form, it should be submitted according to the provider's established procedures. This may involve sending the form to a designated office or entering the information into a digital system. Ensuring timely submission is important for accurate record-keeping and continuity of care.