Read all the instructions in red to complete the 2nd page of the ITR information.  Click "Finish" at the bottom of the screen to register your data and continue.

ValueOptions

Inpatient Treatment Report (ITR)

 
Enter whether or not client has substance abuse issues.  For practice click the button beside "NO".
Substance Use/Abuse: NO UNKNOWN   YES

If yes, please complete below.
  
Substance Total Yrs. Use Length Curr. Use Amount Frequency

  ?

?  

?

  ?  

?

  ?  

  ?

  ?  
*pulled from SA History Section of DA
  
Withdrawal Symptoms: Check all that apply. None
If there were substance abuse issues you would select "YES" for all that applied.   For practice we will leave them blank.

Nausea:

 Sweating: Tremors: Past DTs:

Vomiting:

 Agitation: Blackouts: Current Seizures:

Cramping:

Hallucinations: Current DTs: Past Seizures:
Vitals: (if Detox or Relevant):
Again this information would only be entered for substance abuse clients.  For practice we will leave this section blank.
BP: Temp: Pulse: Resp: BAL:
UDS: Outcome: If positive, for what?: CIWA:

Longest period of sobriety:

Relapse Date:

 ?
  
Asam Dimensions:
This would only be entered for substance abuse clients.  For practice we will leave this section blank.

1: Intoxicated/WD Potential:

4: Readiness to Change:

2: Biomedical Conditions:

5: Relapse Potential:

3: Emot/Beh/Cog Condtns:

6: Recovery Environment:
 
Treatment Request: Admit Date:  ?
(Note well:   Each level of care, ECT and/or Psych Testing requires seperate precertification.)
Enter whether or not family/couples therapy is indicated.

Enter the date of the appointment that has been set up. 
For practice click the down arrow and select "YES".

For practice click in the box and type "02/10/2007".   

Is family/couples therapy indicated?:

If yes, date of appt: 

?
    
For practice click in the box below

For practice click in the box

to select fixed lenth program.

below and type 3 months.    

Involuntary Court Ordered Fixed Length Program specify length:
       

For practice click in the  

For practice click in the box    

  box below and type "2x". 

  below and type "week".              

Frequency of program =  

per: 
 
Reason for Continued Stay:
Enter whether or not the conditions below are reasons for the clt's continued stay.  For practice click the down arrows and select "YES" for "Remains symptomatic, Conduct family therapy, and Stabilize medications".
Remains symptomatic: Has not achieved treatment goals:
Conduct family therapy: Finalize dischg. plan:
Stabilize medications: Other:
Specify if 'Other':

 

Barriers to Discharge:

Enter whether or not the conditions below are barriers to the clts discharge from the program.  For practice leave these blank.
Discharge treatment setting not available: Adequate Housing/Residence:
Transportation: Lack of Community Supports:
Legal Mandate: Treatment Non-Compliance:
Other:
Specify if 'Other':

 

Baseline Functioning:

Enter any baseline functioning.  For practice click the down arrows and select "YES" for "Holds Job, Manages Meds/Med compliant".
Holds Job: Functions independently/ADLs Satisfactory:
Asymptomatic: Abstinent:
Manages Meds/Med Compliant: Other:
Specify if 'Other':

 

Discharge Plan:

   

Enter the expected D/C date.  For practice Enter the estimated return to work date.  For
click in the box and type "3/31/07". practice click in the box and type "4/02/07".
Expected D/C Date if known: ? Estimated return to work date: ?

     

Enter the planned D/C level of care.
For practice click the down arrow
and select "Outpatient".
Planned D/C Level of Care: Specify if 'Other':

                         

Enter the planned D/C residence.   For practice
click the down arrow and select "Home".
Planned D/C Residence: Specify if 'Other':
If 'Home': Alone
Select "w/Others". w/Others
 
Discharge Information:      (to be included upon discharge)
Enter discharge information (upon discharge). 
Actual Discharge Date: ? For practice click in the box to the left and type in "3/31/07".
Primary Discharge Diagnosis: ? For practice click in the box to the left and type in "309.0".
Discharge GAF: For practice click in the box to the left and type in "060".

Select "Improved".
Discharge Condition: Improved No change Worse  

 

Treatment Involved the      (check all that apply)

Following:

Enter whether or not treatment involved any of the following.  For practice click the down arrows and select "YES" for "Family and OP Provider".
Adverse Incident:    OP Provider:   
Child Protection:    Other Support Systems:  
EAP:   PCP:  
Family:   None:  
Legal System:    Other:  
Specify if 'Other':
                  

 

Enter the total # of days/sessions used.
For practice click in the box and type in 20.
Total # of Days/Sessions used:   

                   

Enter whether or not discharge plans are in place.
For practice click the down arrow and select "YES".
Discharge plans in place?:   

     

Enter the type of discharge.  For practice
click in the button to select planned.
Type of discharge:     Planned AMA

      

Enter whether or not Private Care Physician was notified.
For practice click the down arrow and select "NO".
PCP Notified?:   
 
Enter the D/C level of care.  For practice click
the down arrow and select "Outpatient".
Actual D/C Level of Care:

Specify if 'Other':

       

Enter the D/C Residence.  For practice
click the down arrow and select "Home".
Actual D/C Residence:

Specify if 'Other':

If 'Home': Alone
For practice click in the button to select "w/Others". w/Others

 
Member/Family Member Name for Follow Up: Enter family member name for any follow up.  For practice click in the box and type in "JAMES BOND".
         
Relationship: Enter the relationship.  For practice click in the box and type in "SPOUSE".
                         
Phone #: Enter the phone number.  For practice click in the box and type in "704-012-3456".
                       
  
AfterCare Behavioral Health Provider: Enter if clt does not have an aftercare behavioral health provider.  For practice leave this blank.
                             
AfterCare Provider Name: Enter provider name.  For practice click in the box and type "JOE'S".

                

After Care Provider Phone: Enter the phone number.  For practice click in the box and type "704-789-4561".
              
Scheduled Appointment Date: ? Enter the appointment date.  For practice click in the box and type "04-04-07".
                            
Type of Appointment: Enter the type of appt.  For practice click the down arrow and select "Mental Health".
            
  
Prescribing Physician: Enter if you do not know the prescribing physician or if the clt has not arranged with the prescribing physician.  For practice leave this blank.
                 
Prescribing Physician Name: Enter the prescribing physician name.  For practice click in the box and type in "Dr. Barney Rubble".
                   
Prescribing Physician Phone: Enter the phone #.  For practice click in the box and type "704-111-1111".
                            
Prescriber: Enter the type of doctor the prescribing physician is.  Click the down arrow and select "Psychiatrist".
            
Scheduled Appointment Date: ? Enter the scheduled appt. date.  For practice click in the box and type in "04-2-07".
 
                                                Finish       Cancel