Read all the instructions in red to complete the ITR information.  Click "Finish Page 1" at the bottom of the screen to register your data and continue.

ValueOptions

Inpatient Treatment Report (ITR)

 
Enter the requested start date for authorization.
This will default to the current date but you may
enter whatever date you wish.  For practice we
will leave the date that is already entered.
Requested Start Date for this Authorization:     ? 
              
Enter the level of Care.  For practice click If the level of care was not in the list of selections
the down arrow and select "IOP/SOP". you would enter the level of care here.
Level of Care: Specify if 'Other':

Tx Unit/Program:

Enter this information if client is on a specialty unit.  For practice leave this blank.
     

Type of Review:

Enter the type of review.  For practice click the down arrow and select "Concurrent".
     

Type of Care:

Enter the type of service.   For practice click the down arrow and select "Mental Health".
     

Precipitating Event:

Enter what has happend to cause the client to be admitted.  For practice click in the box and type "Client is very depressed".
      

Member's Current Location:

Enter the current location of the client at this time.  For practice click the down arrow and select "Provider's Office".
Demographics: The first 4 lines will be display only.

Member's Name:

FNAME MIDNM ADAMS

Date of Birth:

01/01/1980

Member/Policyholder ID#:

123-45-6789-S

Tel #:     

704-555-5555

Member's City/State:

BESSEMER CITY, NC

Insured's Employer/Benefit Plan: 

Facility:

  ?  SUE'S PLACE Enter your provider ID number.  The information may already be there as it is here.
     
Facility ID: Enter the Value Options facility ID number.  For practice click in the box and type in "VO123".
     
Facility Address: This information is already entered for you.
    
Facility City: This information is already entered for you.
     
Facility State: NORTH CAROLINA This information is already entered for you.
      
Facility Zip: This information is already entered for you.
     
Attending Provider: This information is already entered for you.
     
Attending Phone: Enter your phone number.  For practice click in the box and type "704-123-4567".
     
UR Name: Enter the contact person at your facility for clinical reviews/additional information.  For practice click in the box and type "SUZIE QUE".
      
Enter the phone number for the contact person.

Enter the fax number for the contact

For practice click in the box and type

person.  For practice click in the box
"704-234-5678".

and type "704-345-6789".                   

UR Phone:

UR Fax#:

DSM-IV Diagnosis: This information is display only.
Axis I: 1) 309.0 BRIEF DEPRESSIVE REACTION 2) MANIC DIS SINGLE EPI MODERATE
Axis II: 1) V71.09 NO DIAG OR COND ON AXES I/II 2) 799.9 DIAGNOSIS DEFERRED
Axis III: 1) 799.9 DIAGNOSIS DEFERRED 2) 799.9 DIAGNOSIS DEFERRED
Axis IV: 1) 799.9 DIAGNOSIS DEFERRED 2) 799.9 DIAGNOSIS DEFERRED

Axis V:

Current GAF:

Highest GAF prev. year:

      070
Current Risks:
0=none; 1=mild, ideation only; 2=moderate, ideation with EITHER plan or history of attempts; 3=severe, ideation AND plan with either intent or means; na=not assessed
Click the down arrows and

Click the down arrows and select "NO" for all.
select "None" for both.
Risk to Self (SI):

Ideation?:

Intent?:

Plan?:

Means?:

Risk to Others (HI):

 Ideation?: Intent?:

Plan?:

 Means?:
      
Click the down arrows and select "NO" for all 3. Leave the boxes below blank because there were no serious attempts.
Current serious attempts:  Self or Others?:
Prior serious attempts:  Self or Others?:
Prior serious gestures:  Self or Others?:
Date of the most recent attempt or gesture:     ?

Current Impairments:

0=none; 1=mild; 2=moderate; 3=severe; na=not assessed

Click the down arrows and select "3=severe" for the following:  Mood Disturbance, Anxiety, Activities of Daily Living, Medical/Physical Conditions, Job/School Performance, and Social/Marital/Family Problems.   Select "0=none" for the rest.

Mood Disturbance:

Medical/Physical Conditions(s):
Anxiety: Substance Abuse/Dependence:
Psychosis: Job/School Performance:
Thinking/Cognition/Memory: Social/Marital/Family Problems:
Impulsive/Reckless/Aggressive: Legal:
Activities of Daily Living:
Wieght Loss Assoc. with Eating D/O:
The information below would only be entered if
there was wieght loss assoc. with an eating D/O.

Gain or Loss?:

  of:    lbs.

Current weight =

 lbs.

                  

Height =

 ft.  in.
You would click one of the radio buttons if there was no treatment history or it was unknown.  Leave these blank for training purposes.
Mental Health/Psychiatric Treatment History: None Unknown
     
Click in the box Click the down arrow

Click the down arrow
beside "Outpatient". and select "Improved".

and select "Good".   

Outpatient. Outcome: Treatment compliance (non-med):
 
IOP/Partial.
 
Inpatient/Residential/Group Home.
Click in the radio button
beside "None".
Substance Abuse Treatment History: None Unknown
 
Outpatient.
 
IOP/Partial.
 
Inpatient/Residential/Group Home.
 
Other Treatment History:
Click the down arrows below and select "YES" for "Current psychotropic meds?".  Select "NO" for everything else.

Mandatory workplace referral?:

  

EAP Involved?:

  

EAP Name:

Is member currently receiving disability benefits?:

  

Current psychotropic meds?:

  
     
Current Psychotropic Medications Dose Frequency Usually Adherent?
Trileptal 300 mg 1 bid YES
Prozac 20 mg 1 qid YES
** Current medications are pulled from the Crisis portion of the PCP
  
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