The Ohio Behavioral Discharge Form is a crucial document used to record the discharge details of individuals receiving behavioral health services in Ohio. It captures essential information about the client’s treatment journey, including their progress, reasons for discharge, and relevant personal details. This form not only facilitates a smooth transition for clients but also helps service providers maintain comprehensive records for future reference.
The Ohio Behavioral Discharge Form serves as a crucial tool for documenting the discharge process for clients in behavioral health services. It captures essential client information, including the unique provider number, episode number, and client identification details such as name and date of birth. The form outlines the last date of service and the discharge date, which are vital for maintaining accurate records. A key aspect of the form is the discharge reason, which offers multiple options ranging from successful completion of treatment to involuntary discharge due to non-participation or rule violations. It also addresses referrals to other programs and notes circumstances like incarceration or client relocation. Additionally, the form collects information about the client’s educational background, living arrangements, and health conditions, ensuring a comprehensive overview of the client's situation at discharge. By documenting these factors, the form not only aids in continuity of care but also helps in understanding the broader context of the client's journey through treatment.
Ohio Behavioral Health
Integrated ODMH/ODADAS Discharge Form
Unique Provider Number:
Episode Number:
Name (first/last):
Paying Board:
Unique Client ID:
Date of Birth (mm/dd/yyyy):
Last Date of Service:
Discharge Date:
Discharge Reason
Successful Completion/Graduate
Assessment & evaluation only, successfully completed, no further services recommended
Assessment & evaluation only, successfully completed, client rejected recommendations
Left on own, against staff advice with SATISFACTORY Progress
Left on own, against staff advice with UNSATISFACTORY Progress
Involuntarily discharged due to non-participation
Involuntarily discharged due to violation of rules
Referred to another program or service with SATISFACTORY Progress
Referred to another program or service with UNSATISFACTORY Progress
Incarcerated due to Offense Committed while in Treatment with SATISFACTORY Progress
Incarcerated due to Offense Committed while in Treatment with UNSATISFACTORY Progress
Incarcerated due to Old Warrant/Charge from before Treatment with SATISFACTORY Progress
Incarcerated due to Old Warrant/Charge from before Treatment with UNSATISFACTORY Progress
Transferred to Another Facility for Health Reasons
Death
Client Moved
Needed Services Not Available
Other
Education Type – Choose if K-12 Selected:
Primary Income/Support (Select One)
Did client choose another provider due to
religious preference?
Not Enrolled
Wages/Salary
Yes
No
Not SBH (Client doesn’t have an IEP)
Family/Relative
Highest Educational Level Completed
SBH (Client has an IEP )
Public Assistance
< 1st Grade
10th Grade
Employment Status (Choose One)
Retirement/Pension
1st Grade
11th Grade
Full Time
Disability
2nd Grade
12th Grade
Part Time
Other
3rd Grade
Tech School
Sheltered
Unknown
4th Grade
Some College
Unemployed, but actively looking for work
None
5th Grade
2 Yr Coll Degree
Living Arrangements (Choose One)
6th Grade
4 Yr Coll Degree
Not in Labor Force (Choose One Below)
Independent living (own home)
7th Grade
Grad Degree
Homemaker
Homeless
8th Grade
Student
Others’ Home
9th Grade
Volunteer
Residential Care / Group Home / ACF
Retired
Child Residential Treatment Center
Educational Enrollment
Pre-School
Voc/Job Training
Disabled
Respite Care
K-12th Grade
College
Inmate
Foster Care
GED Classes
Engaged in Residential/Hospitalization
Crisis Care
Other: Literacy,
Temporary Housing
Adult Basic Ed, etc
Community Residence
Living Arrangements (continued)
Drug of Choice (Continued)
ODMH: BIOMARKERS
Nursing Facility
Non-prescription Methadone
Source of Height/Weight Information
Licensed MR Facility
Other Opiates and Synthetics
-Reported
State MH/MR Institution
PCP
Hospital
Other Hallucinogens
Height and Weight
Correctional Facility
Methamphetamines
Height (feet and inches)
Other Amphetamines
|
Other Stimulants
Weight (lbs)
Benzodiazepines
Global Assessment of
Functioning
Other Non-Barbiturate Tranquilizers
Physical Health Conditions
Diagnosis Type (Choose One)
Barbiturates
Does client report/provide evidence of any of the
DSM IV
ICD9
Other Non-Barb. Sedatives/Hypnotics
following conditions in past year?
Diabetes
Primary Diagnosis Code:
Inhalants
Over-the-Counter Medications
High Cholesterol
Nicotine
Cardiovascular Disease (heart attack, stroke)
Secondary Diagnosis Code:
Other Medications
High blood pressure
Cancer
Frequency of Use
Kidney Disease/Failure
– 3 X Past Week
Bowel Obstruction (eg, constipation)
Tertiary Diagnosis Code:
– 2 X in Past Mo
– 6 X Past Week
Respiratory Disease (eg, COPD)
Special Populations (Select all that Apply)
Route of Administration
Health Care Utilization
SMD/SED
Oral
Injection
How frequently (in days) has the client used the
Alcohol/Other Drug Abuse
Smoking
following since admission or last update?
Forensic Status
Inhalation
Hospital Admissions
Developmentally Disabled
Age of First Use – First
Deaf/Hard of Hearing
Intoxication
Emergency Room Visits/Admits
Blind/Sight Impaired
Primary AOD Code:
(psychiatric or physical health)
Physically Disabled
Number of Arrests past 30 days
Outpatient Primary Care Visits
Sexual Abuse Victim
(AOD NOM)
(physical health)
Domestic Violence Victim/Witness
Primary Reimbursement (Select One)
Dental Visits
Child of Alcohol/Drug Abuser
Self-Pay
HIV/AIDS
Blue Cross/Blue Shield
Evidence Based Practices
Suicidal
Medicare
Did the client receive any of the following EBPs
Language Barriers/English 2ND Lang.
Medicaid
since admission or last update?
Hepatitis C
Other Government Support
Adult Practices
Transgendered
Worker’s Compensation
Supportive Housing
In Custody/Child Welfare
Other Private Health Insurance
Supported Employment
Multiple Service System Involvement
No Charge
Assertive Community Treatment (ACT)
Other Payment Source
Early Childhood: At Risk for SED
Family Psycho-Education
Sexual Offender
IDDT
Frequency of attendance at self-help
Bisexual/Gay/Lesbian
programs in the 30 days prior to discharge
WMR/Illness Self-Management
Military Family
No attendance in past month
Medication Management
Drug of Choice (Primary Choice)
1-3 X in past mo.
4-7 X in past mo.
Child & Adolescent Practices
Alcohol
8-15 X in past mo.
16-30 X in past mo.
Therapeutic Foster Care
Cocaine/Crack
Some but unknown
Multi-Systemic Therapy (MST)
Functional Family Therapy
Marijuana/Hashish
Does the client use tobacco products?
Heroin
Don’t Know
Intensive Home-based Therapy (IBHT)
Drug of Choice (Secondary)
Drug of Choice (Tertiary)
No use Past Mo
1 – 3 X Past Week
1 – 2 X in Past Mo
3 – 6 X Past Week
Daily
Secondary AOD Code
Tertiary AOD Code
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