CalOMS Admission. Page 1 of 6

Transcription

1 CalOMS Form All fields (unless labeled optional) must be completed CalOMS Admission Client Profile Client First Name Provider Client ID (optional) Client Last Name SSN - - Middle Initial Drivers License State Birth First Name Drivers License # Birth Last Name Place of Birth (Enter if not CA or USA born) Mother s First Name County: State Abbrev: Gender (circle one) 1. Male 2. Female 3. Other Consent on File? (circle one) 1. Yes 0. No Medi-Cal Beneficiary? 1. Yes 0. No Current Zip Code (enter if homeless) DOB / / Additional Information Race (enter code(s) from below- if multiracial, may select up to 5) Ethnicity (check one) Not Hispanic Mexican/Mexican American Cuban Puerto Rican Other Hispanic/Latino US Veteran? (circle one) 1. Yes 0. No Disability? (circle) None Visual Hearing Speech Mobility Mental Developmentally Disabled Other 01 White 05 Asian Indian 09 Guamanian 13 Laotian 17 Other Race 02 Black/African American 06 Cambodian 10 Hawaiian 14 Samoan 18 Mixed Race 03 American Indian 07 Chinese 11 Japanese 15 Vietnamese 04 Alaskan Native 08 Filipino 12 Korean 16 Other Asian Intake Intake Facility Intake Date / / Intake Staff Pregnant? 1. Yes 0. No Initial Contact Due Date / / Residence (county) Life Threatening Chronic Illness (circle one) 1. Yes 0. No Referral Contact Injection Drug User (circle one) 1. Yes 0. No Referral Date / / Presenting Problem: Assessment Date / / Return Court Date / / Source of Referral (select code below): 01 Individual, including self-referral Step Mutual Aid 11 Comprehensive Drug Court Implementation (CDCI) 02 Alcohol/Drug Abuse program 07 SACPA Court/Probation 12 Non SACPA Court/Criminal Justice 03 Other Health Care provider 08 SACPA Parole 13 Other Community Referral 04 School/Educational 09 DUI/DWI 14 Dependency Court/Child Protective Services 05 Employer/EAP 10 State Drug Court Partnership (DCP) Admission Profile Admission Date / / CalWORKS Recipient? 1. Yes 0. No Admission Type 1. initial admission 2. transfer Treatment Under CalWORKS? 1. Yes 0. No No of Days Waited to Enter Treatment Special Services Contract ID Not Applicable Number of Prior Episodes Special Services Contract Cnty Not Applicable Program Type (select code below): 01. NonRes Opt Tx Recovery 02. NonRes Opt Day Prgrm Inten 03. NonRes Opt Detox 04. Res Detox (hospital) 05. Res Detox (non-hospital) 06. Res Tx Rec (30 days or less) 07. Res Tx Rec (31 days or more) Use the following codes for answers such as: Not Applicable NA (allowed for questions marked with ) Declined to State DS (allowed for questions marked with ) Unknown/Don t Know UNK (allowed for questions marked with ) Unable to Answer UA (allowed for questions marked with ) Unable to Answer is allowed only if type of service is Detox or disability includes developmentally disabled Page 1 of 6

2 CalOMS Admission Primary Drug Type Alcohol & Drug Use Secondary Drug Type No of Days used in past 30 No of Days used in past 30 Route of Administration Age of First Use: Route of Administration Age of First Use: Tertiary Drug Type No of Days used in past 30 Number of Days Used Alcohol in Past 30 Days Number of Days Used IV in Past 30 Days Route of Administration Age of First Use: Used Needles in Past 12 Months? 1. Yes 0. No Route of Administration Codes 01 Oral 02 Smoking 03 Inhalation 04 Injection None/NA Other Drug Type Codes (must specify name of drug if *) 00 None 05 Methamphetamine 10 PCP 15 OxyCodone/OxyContin 20 Other Club Drugs* 01 Heroin 06 Other Amphetamines* 11 Other Hallucinogens* 16 Other Opiates Synthetics* (Unknown) 02 Alcohol 07 Other Stimulants* 12 Tranquilizers 17 Inhalants* (Other*) 03 Barbiturates* 08 Cocaine/Crack 13 Other Tranquilizers* 18 Over the Counter* 04 Other Sedative/Hypnotics* 09 Marijuana/Hashish 14 NonPrescribed Methadone 19 Ecstasy Family / Social Current Living Arrangements (check one) Homeless Dependent Living Independent Living Number of Children Under 18? Number of Children Age 5 or Less? Number of Days Social Support Recovery Activities in Past 30 Days Number of Days Living w/ Alcohol or Drug User in Past 30 Days Number of Days Serious Family Conflict in Past 30 Days Number of Children Living w/ Someone Else because of a Child Protection Court Order Number of Children Living w/ Someone Else for whom Parental Rights have been Terminated Employment Status (enter code) Employment Number Paid Work Days in Past 30 Days Enrolled in School? 1. Yes 0. No Highest School Grade Completed Enrolled in Job Training? 1. Yes 0. No 1. FT (35 hrs or more) 2. PT (less than 35 hrs) 3. Unemployed, looking for work 4. Unemp, not seeking work 5. Not in labor force (not seeking) Criminal Justice Number of Arrests Last 30 Days CDC Number Number of Jail Days in Last 30 Parolee Srvcs Network (BASN) 1. Yes 0. No Number of Prison Days in Last 30 Female Offender Tx Pr (FOTP) 1. Yes 0. No Criminal Justice Status (enter code) FOTP Priority Status (code) Criminal Justice Status Codes 01 Not applicable 02 Under parole supervision by CDC 03 parole from any other jurisdiction 04 On probation from any jurisdiction 05 Other diversion (PC1000) 06 Incarcerated 07 Awaiting trial/charges/sentencing (Client unable to answer) FOTP Priority Status Codes 01 Completed FF, released, enrolled in tx prgrm 02 Any woman paroling from CIW 03 Completed FF, goes direct to FOTP (None or N/A) Medical / Physical / Mental Health No of Times in ER Past 30 Days HIV Tested 1. Yes 0. No No of Hospital Overnights Past 30 Days HIV Test Results Received 1. Yes 0. No No of Days Medical Problems Past 30 Mental Illness Diagnosed 1. Yes 0. No Meds Prescribed as Part of Tx (code) Mental Health Meds Past 30 Days 1. Yes 0. No No. Times Outpatient ER MH in Past 30 Days No. of 24-hr Psych Facility Stays Past 30 Days Diagnosed Communicable Diseases ( if yes) Tuberculosis Hepatitis C Sexually Transmitted Disease Medication Codes 01 None 02 Methadone 03 LAAM 04 Buprenorphine (Subutex) 05 Buprenorphine (Suboxone) Other See Next Page for Discharge Form See page 1 footer for symbol explanations Page 2 of 6

3 CalOMS Discharge CADDS? 0 Required if admission date is prior to 1/1/ 2006 Discharge Profile Discharge Date / / Discharge Status (enter code) Discharge Status Codes 01 Completed Treatment/Recovery Plan, Goals/Referred 05 Left Before Completion w/ Unsatisfactory Progress/Referred 02 Completed Treatment/Recovery Plan, Goals/Not Referred 06 Left Before Completion w/ Unsatisfactory Progress/Not Referred 03 Left Before Completion w/ Satisfactory Progress/Referred 07 Death 04 Left Before Completion w/ Satisfactory Progress/Not Referred 08 Incarceration Client Profile (complete only if there are changes) Client First Name Provider Client ID (optional) Client Last Name SSN - - Middle Initial Drivers License State Birth First Name Drivers License # Birth Last Name Place of Birth (Enter if not CA or USA born) Mother s First Name County: State Abbrev: Gender (circle one) 1. Male 2. Female 3. Other Consent on File? (circle one) 1. Yes 0. No Medi-Cal Beneficiary? 1. Yes 0. No Current Zip Code (enter if homeless) DOB / / Alcohol & Drug Use Primary Drug Type Secondary Drug Type No of Days used in past 30 No of Days used in past 30 Route of Administration Age of First Use: Route of Administration Age of First Use: Tertiary Drug Type Number of Days Used Alcohol in Past 30 Days No of Days used in past 30 Number of Days Used IV in Past 30 Days Route of Administration Age of First Use: Used Needles in Past 12 Months? 1. Yes 0. No Route of Administration Codes 01 Oral 02 Smoking 03 Inhalation 04 Injection None/NA Other Drug Type Codes (must specify name of drug if *) 00 None 05 Methamphetamine 10 PCP 15 OxyCodone/OxyContin 20 Other Club Drugs* 01 Heroin 06 Other Amphetamines* 11 Other Hallucinogens* 16 Other Opiates Synthetics* (Unknown) 02 Alcohol 07 Other Stimulants* 12 Tranquilizers 17 Inhalants* (Other*) 03 Barbiturates* 08 Cocaine/Crack 13 Other Tranquilizers* 18 Over the Counter* 04 Other Sedative/Hypnotics* 09 Marijuana/Hashish 14 NonPrescribed Methadone 19 Ecstasy Family / Social Current Living Arrangements (check one) Homeless Dependent Living Independent Living Number of Children Under 18? Number of Children Age 5 or Less? Number of Days Social Support Recovery Activities in Past 30 Days Number of Days Living w/ Alcohol or Drug User in Past 30 Days Number of Days Serious Family Conflict in Past 30 Days Number of Children Living w/ Someone Else because of a Child Protection Court Order Number of Children Living w/ Someone Else for whom Parental Rights have been Terminated See page 1 footer for symbol explanations Page 3 of 6

4 CalOMS Discharge Employment Employment Status (enter code) Enrolled in School? 1. Yes 0. No Number Paid Work Days in Past 30 Days Enrolled in Job Training? 1. Yes 0. No 1. FT (35 hrs or more) 2. PT (less than 35 hrs) 3. Unemployed, looking for work 4. Unemp, not seeking work 5. Not in labor force (not seeking) Criminal Justice Number of Arrests in Last 30 Number of Jail Days in Last 30 Number of Prison Days in Last 30 Medical / Physical / Mental Health HIV Tested 1. Yes 0. No No of Times in ER Past 30 Days HIV Test Results Received 1. Yes 0. No No of Hospital Overnights Past 30 Days Mental Illness Diagnosed 1. Yes 0. No No of Days Medical Problems Past 30 Mental Health Meds Past 30 Days 1. Yes 0. No No. Times Outpatient ER MH in Past 30 Days No. of 24-hr Psych Facility Stays Past 30 Days Pregnant at Any Time During Treatment? 1. Yes 0. No Outcome of Pregnancy? See Next Page for Annual Update Form See page 1 footer for symbol explanations Page 4 of 6

5 CalOMS Annual Update Annual Update Profile Admission Date / / Update Date / / Number of the Annual Update being reported Update must be between 9 & 12 months past admission date Client Profile (complete only if there are changes) Client First Name Provider Client ID (optional) Client Last Name SSN - - Middle Initial Drivers License State Birth First Name Drivers License # Birth Last Name Place of Birth (Enter if not CA or USA born) Mother s First Name County: State Abbrev: Gender (circle one) 1. Male 2. Female 3. Other Consent on File? (circle one) 1. Yes 0. No Medi-Cal Beneficiary? 1. Yes 0. No Current Zip Code (enter if homeless) DOB / / Alcohol & Drug Use Primary Drug Type Secondary Drug Type No of Days used in past 30 No of Days used in past 30 Route of Administration Age of First Use: Route of Administration Age of First Use: Tertiary Drug Type Number of Days Used Alcohol in Past 30 Days No of Days used in past 30 Number of Days Used IV in Past 30 Days Route of Administration Age of First Use: Used Needles in Past 12 Months? 1. Yes 0. No Route of Administration Codes 01 Oral 02 Smoking 03 Inhalation 04 Injection None/NA Other Drug Type Codes (must specify name of drug if *) 00 None 05 Methamphetamine 10 PCP 15 OxyCodone/OxyContin 20 Other Club Drugs* 01 Heroin 06 Other Amphetamines* 11 Other Hallucinogens* 16 Other Opiates Synthetics* (Unknown) 02 Alcohol 07 Other Stimulants* 12 Tranquilizers 17 Inhalants* (Other*) 03 Barbiturates* 08 Cocaine/Crack 13 Other Tranquilizers* 18 Over the Counter* 04 Other Sedative/Hypnotics* 09 Marijuana/Hashish 14 NonPrescribed Methadone 19 Ecstasy Family / Social Current Living Arrangements (check one) Homeless Dependent Living Independent Living Number of Children Under 18? Number of Children Age 5 or Less? Number of Days Social Support Recovery Activities in Past 30 Days Number of Days Living w/ Alcohol or Drug User in Past 30 Days Number of Days Serious Family Conflict in Past 30 Days Number of Children Living w/ Someone Else because of a Child Protection Court Order Number of Children Living w/ Someone Else for whom Parental Rights have been Terminated Employment Employment Status (enter code) Enrolled in School? 1. Yes 0. No Number Paid Work Days in Past 30 Days Enrolled in Job Training? 1. Yes 0. No 1. FT (35 hrs or more) 2. PT (less than 35 hrs) 3. Unemployed, looking for work 4. Unemp, not seeking work 5. Not in labor force (not seeking) See page 1 footer for symbol explanations Page 5 of 6

6 CalOMS Annual Update Criminal Justice Number of Arrests in Last 30 Number of Jail Days in Last 30 Number of Prison Days in Last 30 Medical / Physical / Mental Health HIV Tested 1. Yes 0. No No of Times in ER Past 30 Days HIV Test Results Received 1. Yes 0. No No of Hospital Overnights Past 30 Days Mental Illness Diagnosed 1. Yes 0. No No of Days Medical Problems Past 30 Mental Health Meds Past 30 Days 1. Yes 0. No No. Times Outpatient ER MH in Past 30 Days No. of 24-hr Psych Facility Stays Past 30 Days Pregnant at Any Time During Treatment? 1. Yes 0. No Outcome of Pregnancy? Use the following codes for answers such as: Not Applicable NA (allowed for questions marked with ) Declined to State DS (allowed for questions marked with ) Unknown/Don t Know UNK (allowed for questions marked with ) Unable to Answer UA (allowed for questions marked with ) Unable to Answer is allowed only if type of service is Detox or disability includes developmentally disabled Page 6 of 6