DIAGNOSIS TEDS – SUPPLEMENTAL – BUT NOT SOMMS DSM DIAGNOSIS AT ADMISSION SUDS 4 DESCRIPTION: THE DIAGNOSIS OF THE SUBSTANCE ABUSE PROBLEM FROM THE AMERICAN PSYCHIATRIC ASSOCIATION'S DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS. DSM IV IS PREFERRED, BUT USE OF THE THIRD EDITION, OR ICD CODES IS PERMISSIBLE. IF THE DSM IV IS NOT USED, THE STATE MUST SPECIFY THE CODING SYSTEM IN STATE CROSSWALK. GUIDELINES: VALID ENTRIES GENERALLY WILL HAVE 3 CHARACTERS AND A DECIMAL POINT FOLLOWED BY 1 OR 2 CHARACTERS. IF A VALID CODE HAS FEWER THAN 5 CHARACTERS AND A DECIMAL, THE CODE SHOULD BE LEFT JUSTIFIED SO THAT ALL REMAINING CHARACTERS ON THE RIGHT ARE BLANK. WHILE A THREE CHARACTER CODE WITH NO DECIMAL OR FOLLOWING DIGITS WILL BE ACCEPTED, VIRTUALLY ALL SUBSTANCE ABUSE DIAGNOSIS CODES HAVE AT LEAST ONE DIGIT TO THE RIGHT OF THE DECIMAL. STATES SHOULD STRIVE TO OBT AIN COMPLETE CODING WITH SUFFICIENT DIGITS TO ACCURATELY CODE THE DIAGNOSIS. VALID ENTRIES: (XXX.XX) (XXX.X- ) (XXX . - - ) (XXX - - - ) WHERE – REPRESENTS A BLANK. 999.97 UNKNOWN 999.9 8 NOT COLLECTED UNKNOWN (999.97) USE THIS CODE IF THE STATE COLLECTS THESE DATA, BUT FOR SOME REASON A PARTICULAR RECORD DOES NOT REFLECT AN ACCEPTABLE VALUE. NOT COLLECTED (999.98) USE THIS CODE IF THE STATE DOES NOT COLLECT THESE DATA FOR SUBMISSION TO TEDS. GPRA No similar measure South Carolina Admission and Discharge Axis I: Clinical Disorders/Other Conditions That M ay be a Focus of Clinical Attention (DSM-IV) Primary Diagnostic Impression . Secondary Diagnostic Impression . Primary Diagnosis Specifier 1: Physiological Dependence 1 2 With Physiological Dependence Without Physiological Dependence Secondary Diagnosis Specifier 1: Physiological Dependence 1 2 With Physiological Dependence Without Physiological Dependence Primary Diagnosis Specifier 2: Remission 1 2 3 4 5 Early Partial Remission Early Full Remission Sustained Partial Remission Sustained Full Remission Not Applicable Secondary Diagnosis Specifier 2: Remission 1 2 3 4 5 Early Partial Remission Early Full Remission Sustained Partial Remission Sustained Full Remission Not Applicable Common Axis I DSM IV Codes 291.0 Alcohol Intoxication Delirium, Withdrawal Delirium 291.1 Alcohol-Induced Persisting Amnestic Disorder 291.2 Alcohol-Induced Persisting Dementia 291.3 Alcohol-Induced Psychotic Disorder with Hallucinations 291.5 Alcohol Induced Psychotic Disorder with Delusions 291.81 Alcohol Withdrawal 291.89 Alcohol-Induced Anxiety, Mood or Sleep Disorder, or Sexual Dysfunction 291.9 Alcohol-Related Disorder Not Otherwise Specified 292.0 Drug Withdrawal 292.11 Drug-Induced Psychotic Disorder with Delusions 292.12 Drug-Induced Psychotic Disorder with Hallucinations 292.81 Drug Intoxication Delirium, Withdrawal Delirium 292.82 Drug-Induced Persisting Dementia 292.83 Drug-Induced Persisting Amnestic Disorder 292.84 Drug-Induced Mood Disorder 292.89 Drug-Induced Anxiety Disorder, Sexual Dysfunction, Sleep Disorder, Intoxication or Persisting Perception Disorder 292.9 Drug-Related Disorder Not Otherwise Specified 303.00 Alcohol Intoxication 303.90 Alcohol Dependence 304.00 Opioid Dependence 304.10 Sedative, Hypnotic, Anxiolytic Dependence 304.20 Cocaine Dependence 304.30 Cannabis Dependence 304.40 Amphetamine Dependence 304.50 Hallucinogens Dependence 304.60 Inhalant/Phencyclidine Dependence 304.80 Polysubstance Dependence 304.90 Other (or unknown) Substance Dependence 305.00 Alcohol Abuse 305.1 Nicotine Dependence 305.20 Cannabis Abuse 305.30 Hallucinogens Abuse 305.40 Sedative, Hypnotic, Anxiolytic Abuse 305.50 Opioid Abuse 305.60 Cocaine Abuse 305.70 Amphetamine Abuse 305.90 Inhalant Hydrocarbons, Phencyclidine or Other (or unknown) Substance Abuse, Caffeine Intoxication 312.31 Pathological Gambling Enter the client's primary diagnosis for Axis I. The decimal is not reported to DAODAS. If a dependence diagnosis (listed above) is indicated, the following 2 specifiers must be completed. If the diagnosis is not one of the dependence diagnoses listed above, the following 2 specifiers are to be skipped. If any diagnosis fields are changed at any time, the computer should be updated and an updated Admission Form should be sent to DAODAS (as a change). Refer to the DSM IV section for a full list of DSM-IV codes that also indicates the validity of the use of each code as the Axis I primary diagnosis, Axis I secondary diagnosis or as an Axis II diagnosis. Enter the client's secondary diagnosis for Axis I. If there is no secondary diagnosis, code V71.09 should be indicated rather than leaving the field blank. The decimal is not reported to DAODAS. Primary Diagnosis Specifier 1 for Axis I: Physiological Dependence 1 With Physiological Dependence 2 Without Physiological Dependence If the primary diagnostic impression for Axis I is a dependence diagnosis, indicate that the dependence is physiological by selecting option 1. Indicate non-physiological dependence by selecting option 2. Skip this field when the diagnosis is not a dependence type. Primary Diagnosis Specifier 2 for Axis I: Remission 1 Early Partial Remission 2 Early Full Remission 3 Sustained Partial Remission 4 Sustained Full Remission 5 Not Applicable For all Axis I primary dependence diagnoses, indicate the appropriate stage of remission. Skip this field when the diagnosis is not a dependence type. Axis II: Personality Disorders/Mental Primary Diagnostic Impression Common Axis II Codes Common DSM-IV Codes - AXIS II Only V62.89 301.0 301.20 301.22 301.4 301.50 301.6 301.7 301.81 301.82 301.83 301.9 317 318.0 318.1 318.2 319 Phase of Life/Religious or Spiritual Problem/Borderline Intellectual Functioning Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Obsessive-Compulsive Personality Disorder Histrionic Personality Disorder Dependent Personality Disorder Antisocial Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Borderline Personality Disorder Personality Disorder Not Otherwise Specified Mild Mental Retardation Moderate Mental Retardation Severe Mental Retardation Profound Mental Retardation Mental Retardation, Severity Unspecified . Retardation (DSM-IV) See DSM-IV Manual for Additional Codes. If appropriate, indicate a personality disorder or mental retardation diagnosis in this area. If there is no Axis II diagnosis, code V71.09 should be indicated rather than leaving the field blank. The decimal is not reported to DAODAS Texas Texas collects Axis III also at discharge (Texas collects all 5 Axes DSM) AXIS III: GENERAL MEDICAL DIAGNOSTIC IMPRESSION (Select up to 5) 001-139 140-239 240-279 280-289 320-389 390-459 460-519 520-579 580-629 630-676 680-709 710-739 740-759 760-779 780-799 800-999 1000-1199 Infectious and Parasitic Diseases Neoplasms Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders Diseases of the Blood and Blood-Forming Organs Diseases of the Nervous System and Sense Organs Diseases of the Circulatory System Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Genitourinary System Complications of Pregnancy, Childbirth, and the Puerperium Diseases of the Skin and Subcutaneous Tissue Diseases of the Musculoskeletal System and Connective Tissue Congenital Anomalies Certain Conditions Originating in the Perinatal Period Symptoms, Signs, and Ill-Defined Conditions Injury and Poisoning Medical Diagnostic Criteria not Indicated South Carolina Severity Indicators 4 = Very Severe Problem) (0 = No Problem, 1 = Mild Problem, 2 = Moderate Problem, 3 = Severe Problem, Indicator Acute Intoxication and/or Withdrawal Potential............................. Biomedical Conditions and Complications....................................... Emotional/Behavioral or Cognitive Conditions and Complications Readiness to Change......................................................................... Relapse, Continued Use or Continued Problem Potential............... Recovery/Living Environment.......................................................... Severity Indicator Scale 0 1 2 3 4 No Problem Mild Problem Moderate Problem Severe Problem Very Severe Problem Measure each of the six indicators listed by the severity scale of 0-4 shown above. 4's should be used to indicate the highest severity (worst prognosis condition) for each indicator and 0's are used to indicate the least severity (best prognosis condition) for each indicator. Thus, a 4 on the Readiness to Change indicator means poor readiness to change and a 4 on Recovery/Living Environment indicates a very poor recovery environment. The Intoxication/Withdrawal severity scale means the immediate presence or immediate risk of intoxication or withdrawal, and a 3 or 4 on this scale means a recommended placement in Level III or Level IV detox, or a hospital. Severity indicators are required for all clients with a primary problem code of alcohol or any drug. All zeros on all six severity indicators (especially on the Admission Form) is unlikely and probably indicates that the fields were skipped. Severity indicators play an important role in determining level of care placement and they can document client progress during treatment. South Carolina Axis IV: Psychosocial & Environmental Problems 01 Problems with Primary Support Group Sexual or Physical Abuse Abuse or Neglect of Child Removal of Child from Home Divorce, Estrangement, Separation, Remarriage Death or Health Problems of Family Member Parenting Skills Sibling Conflict Other Problems Related to the Social Environment Death or Loss of a Friend Inadequate Social Support Living Alone Difficulty with Accult uration Discrimi nation Adj ustment to Life-Cycle Transition Other Educational Problems Academi c Problems Illiteracy Discord with Teachers or Classmates Inadequate School Environment Other Occupational Problems Unemployment Threat of Job Loss Stressful Work Schedule Difficult Work Co nditions Job Dissatisfaction Discord with Boss or Co-Workers Other 05 Housi ng Problems Homelessness Inadequate Housi ng Unsafe Neighborhood Discord with Neig hbors or Landlord Other Economic Problems Extreme Poverty Inadequate Finances Insufficient Welfare Support Other Problems with Access to Health Care Services Inadequate Health Care Services Transportation to Health Care Facilities Not Available Inadequate Health Insurance Other Problems Related to Interaction with Legal System/Crime Arrest Litigation Incarceration Victim of Crime Probation Parole Other Other Psychosocial and Enviro nmental Problems Exposure to Disaster, War, Other Hostilities Discord with No n-Family Caregivers Unavailability of Social Service Agencies Other 06 02 07 08 03 04 09 Select all that apply. Major headings (numbered) must be selected before sub-entries for those headings can be selected. If a major heading is selected, at least one sub-entry for that heading must also be selected. This data helps determine placement. Axis V – 0-100 Axis V: Global Assessment of Functioning Scale Score AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING DIAGNOSTIC IMPRESSION 91-100 81-90 71-80 61-70 51-60 41-50 31-40 21-30 11-20 01-10 0 Superior functioning in a wide range of activities. No symptoms. Good functioning in all areas. Absent or minimal symptoms. Slight impairments in social occupational school functioning. Symptoms transient and expectable reactions to stressors. Some difficulty in functioning. Mild symptoms. Moderate difficulty in functioning. Moderate symptoms. Serious impairment in functioning. Serious symptoms. Major impairment in several areas. Some impairment in reality testing or communication. Inability to function in almost all areas. Behavior influenced by delusions/hallucinations. Serious impairment communic/judgme Some danger of hurting self or others. Gross impairment in communic. Persistent danger of severely hurting self or others, suicidal. Persistent inability to function (hygiene etc). Inadequate information Enter the client's Global Assessment of Functioning (GAF) scale score between 000 and 100. For the majority of clients with AOD problems, the admission GAF score generally falls between 60 and 75, although we do see scores higher and lower than this. Your software will question, but not prohibit, entries below 21 and above 90. This data helps determine placement and can be used to monitor progress during treatment. Amended with DSM IV TR Global Assessment of Functioning (GAF) Scale The GAF Scale reports the clinician’s judgment of the individuals overall level of functioning and is useful in tracking the clinical progress of individuals on global terms, using a single measure. The GAF Scale measures only psychological, social, and occupational functioning. Do not include impairment due to physical or environmental limitations. Rating for TDS should reflect current functioning, i.e., at time of admission and at time of discharge. The GAF is AXIS V of the DSM-IV multiaxial classification. Code: (Note; Use intermediate codes when appropriate. E.g., 45, 68, 72) 100 91 90 81 80 71 70 61 60 51 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interest and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). 50 41 40 31 30 21 20 11 10 1 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Behavior is considerably influenced by delusion or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute). Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death. 0 Inadequate information. Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Readiness to Change Texas Progress Notes and at Discharge (Useful at admission also – predictor of successful completion and useful as stratification and control variable when analyzing client progress measures or outcomes) TREATMENT STAGE Precontemplation Contemplation Preparation Action Maintenance Ohio 25. DIAGNOSIS: This field represents the Diagnosis Type, Primary Diagnosis Code and Secondary Diagnosis Code. The Primary and Secon dary Diagnosis Code is an alphanumeric five-character code; no decimals. Both the Type and Code must be completed. Note: Not all ICD9, DSMIR and DSM IV codes will be accepted. Only Diagnosis Codes which are documented as being accounted for by the MACSIS and Behavioral Health systems will be accepted. 25A. DIAGNOSIS TYPE: A = DSM IIIR B = DSM IV C = ICD9 25B. PRIMARY DIAGNOSIS CODE: Refer to DSM or ICD9 Lists. 25C. SECONDARY DIAGNOSIS CODE: Refer to DSM or ICD9 Lists.