Sandhills Center Inpatient Treatment Report (ITR) by yu1123

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									Sandhills Center IPRS Outpatient Services Request (OSR) Request for Certification
Requested Start date for Certification: / Services Requested: Mobile Crisis Assertive Engagement / Current level of Functioning/Impairment: None Mild Moderate Severe N/A Mood Disturbance Anxiety/Panic Psychosis Cognitive Impairment Impulsiveness Substance Use/Abuse Job/School Difficulties Social/Family Issues Legal Problems (Complete for concurrent certification requests only. Check as applicable.) Remains at high risk Risk Reduced Risk minimal Impairment significant Impairment Function improving Highly symptomatic Symptom improving Self management of symptom No limited progress towards goals/obj Slight progress Progress noted Discharge Barriers to Discharge: Discharge treatment setting not available Transportation Legal Mandate Adequate Housing/Residence Lack of Community Supports Treatment Non-Compliance Other: Baseline Functioning: Holds Job Asymptomatic Manages Meds/Med Compliant Functions Independently/ADL’s Satisfactory Abstinent Other: Discharge Information: (to be included upon discharge) Actual Discharge Date: / / Primary Discharge Diagnosis: Discharge GAF: Discharge Condition: Improved No Change Worse Actual Discharge Level of Care: Outpatient Inpatient 23 hr CSU RTC Partial IOP/SOP Group Home Halfway House Other Actual Discharge Residence: Home ( Alone or w/Others) Nursing Home/SNF/Asst..Living RTC/Group Home/Halfway House Shelter Correctional Facility Foster Care Respite State Hosp Residential Placement Juvenile Detention Transfer to Medical Transfer to Alternate Psych Facility Other:

Type of Review Requested: (select only one) Prospective Concurrent Retrospective Service Category: Mental Health

Substance Abuse

Developmental Disability

Precipitating Event: Provider Information: Name and Credentials of designated provider for utilization review activities: Contact #: Fax #: Member Information: Member Name: DOB: Member #: Member Address:

/

/

Member Current Location: Facility/Agency/Provider ER Home Jail/Detention DSM-IV Diagnosis: (Name & Code) Axis I 1) 2) Axis II 1) 2) Axis III 1) 2) Axis IV 1) 2) Axis V Score Risk for Harm to Self/Others: None Current Risk to self Current Risk to others Yes Current serious attempt(s) Past gestures of self harm Prior self harm attempt(s) Mild

Community Other

Moderate

Severe

If Yes, Explain:

No

Print Name & Clinical Credentials of Person Completing this form:

Instructions for Sandhills Center IPRS Outpatient Services Request (OSR) Request for Certification
Requested Start date for Certification: Enter date Services Requested: Check service. Type of Review Requested: Check type of review. Service Category: Check Category Precipitating Event: Enter brief statement of precipitating event Provider Information: Enter Name, credentials, phone and fax numbers of designated provider contact. Member Information: Enter member’s name, DOB, Member file number and Member address. Member Current Location: Check current location of member DSM-IV Diagnosis: Enter Diagnostic Name & Code and complete Axis 1-V. Axis I Clinical Disorders Axis II Personality Disorders and Mental Retardation Axis III General Medical Conditions Axis IV Psychosocial and Environmental Problems Axis V Global Assessment of Functioning (GAF) Score Risk for Harm to Self/Others: Check all that apply as per clinician’s assessment. Rating 0 = none 1 = mild 2 = moderate Definition No evidence of impairment Occasional impairment or difficulties, but no interference with normal daily activities Currently experiencing difficulties, frequent disruptions in daily activities, requires periodic or continuous assistance with some tasks Currently experiencing severe symptoms, potential risk of harm to self/others, severe distress and/or disruption of daily activities Explain in space provided No response required Discharge Condition: Check descriptor most reflective of current functioning as compared to functioning at admission. Actual Discharge Level of Care: Check or write in level of care which member was discharged into Actual Discharge Residence: Check or write in discharge residence. Baseline Functioning: Check, or write in, all baseline functioning items which the member is currently experiencing that may support member discharge. Discharge Information: (NOTE: to be included upon discharge) Actual Discharge Date: Enter date of discharge. Primary Discharge Diagnosis: Enter Discharge Diagnostic Name(s) and Code(s) Discharge GAF: Enter Discharge GAF score Discharge Barriers to Discharge: Check, or write in, all items which the member is currently experiencing that may impede member discharge. Current level of Functioning/Impairment: Check all that apply as per clinician’s assessment. Note: Complete for concurrent certification requests only.

Print Name & Clinical Credentials of Person Completing this form: Enter printed name with clinical credentials of clinician completing form.

3 = severe

Yes No


								
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