Identification and Summary Sheet (FACE Sheet)

							                                               SCDMH DIVISION OF INPATIENT SERVICES
                             COLUMBIA HOSPITAL PROGRAM IDENTIFICATION AND SUMMARY SHEET                                Page 1of 2
LAST NAME                FIRST NAME                    MI         MAIDEN                   DOB & AGE      CASE TYPE    MED RECORD #
                                                                  NAME/ALIAS

ADMISSION DATE & TIME                       RACE       SEX        MAR ST      RESIDENT’S ADDRESS                  COUNTY OF RESIDENCE


PHONE NUMBER                                      RELIGION            PRIMARY LANGUAGE           EDUCATION         OCCUPATION
H            W

PLACE & ADDRESS OF EMPLOYMENT                                                SOC SECURITY #          MEDICARE #    MEDICAID #


OTHER INS-NAME/POLICY #                             VETERAN/BRANCH/SERVICE DATES                     DATE/CHANGE OF ADMISSION STATUS


NEXT OF KIN/INTERESTED PERSON                                              ADDRESS             PHONE #: HOME
                                                                                                        WORK
                                                                                               A#1
SCREENED BY MHC/CLINIC:                          ___YES      ___NO        REFERRED BY/POINT OF ORIGIN    REFERENCE PHONE #

CENTER/CLINIC NAME:
    ATTENDING PHYSICIAN                                            SOCIAL WORKER                     FACE SHEET COMPLETED BY


MV CASE MANAGER:                                                           INTAKE COUNSELOR:


REASON FOR HOSPITALIZATION:

DISCHARGE DIAGNOSIS:
AXIS I: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

AXIS II: _______________________________________________________________________________________________________

_______________________________________________________________________________________________________________

AXIS III: ______________________________________________________________________________________________________

_______________________________________________________________________________________________________________

AXIS IV: ______________________________________________________________________________________________________

_______________________________________________________________________________________________________________

AXIS V: GAF SCORE:__________________________________________________________________________________________

CONDITION AT DISCHARGE: __________________________________________________________________________________

DISCHARGE DATE/TIME: __________________________                             PHYSICIAN SIGNATURE: ________________________________


             PICTURE                                      PATIENT ID LABEL                                    ALLERGY FLAG


                                                                                                                  OTHER FLAG
                                                     Adm. This Facility       Total DMH Admissions

 SCDMH FORM                                          # ______________         # ______________
 OCT 77 (REV MAR 2009) (F.M. 03 23 2009) M-001
                                                           SCDMH DIVISION OF INPATIENT SERVICES
                                        COLUMBIA HOSPITAL PROGRAM IDENTIFICATION AND SUMMARY SHEET                                                                                   Page 2 of 2
    JUSTIFICATION FOR TWO OR MORE ANTIPSYCHOTIC MEDICATIONS:




    PHYSICIAN’S SIGNATURE:
      Discharge Medications: see Orders for Pass / Discharge medications (M-208EEEEE)
    DISPOSITION & RECOMMENDATIONS FOR NEXT LEVEL OF CARE / GOALS & TREATMENT ISSUES (Include
    patient discharge address if different from information on page 1) AA, NA, Peer support, Social Work & benefits follow-up,
    follow-up on medical conditions):
    _______________________________________________________________________________________________________________________________________

    _______________________________________________________________________________________________________________________________________


    _______________________________________________________________________________________________________________________________________


    _______________________________________________________________________________________________________________________________________




    CLINICIAN SIGNATURE: ____________________________________________                                                                      DATE: _____________________________
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-
    NEXT LEVEL OF CARE PROVIDER APPOINTMENT – document primary appointment here (if discharged to another
    inpatient facility, jail, or prison, the appointment date should match the discharge date.)

    NAME: ____________________________________________ ADDRESS: __________________________________ PHONE: _______________
                 (Center/Case Manager)

    APPT DATE: _____________________ TIME: _____________ SIGNATURE: _______________________________________

    PATIENT SIGNATURE: ______________________________________________                                                                     DATE: _____________________________
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-Document additional appointments as needed (A&D Commission, A&D Counselor, VR, etc) :

    NAME: _______________________________ ADDRESS: _______________________________ PHONE #: _________________

    APPT DATE: __________________ TIME: _______________ SIGNATURE: __________________________________________

    NAME: ______________________________ ADDRESS: _______________________________ PHONE #: __________________

    APPT DATE: ____________________ TIME: ______________ SIGNATURE: _________________________________________

    Items below are to be transmitted to the next
    Level of care provider (attach verification of transmission)
      Continuing Care Plan documents transmitted:                                                                                                         PATIENT ID LABEL
      1. Identification & Summary Sheet
      2. Orders for Pass / Discharge Medications
      3. Nursing Discharge Summary & Instructions
      4. Universal Medication Sheet(s)                                                                                                     OTHER FLAGS


      SCDMH FORM
      OCT 77 (REV MAR 2009) (F.M. 03 23 2009) M-001