Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. Appendix D Summary of All Patient Health Information Requested in Outpatient Treatment Request Forms

01/17/2003

Summary of All Patient Health Information Requested in Outpatient Treatment Request Forms

Summary of All Patient Health Information Requested in Outpatient Treatment Request Forms
  Categorical Narrative Both
Demographic/administrative information
Patient’s Name   11  
Patient’s Date of Birth   10  
Patient’s SSN   10  
Patient’s Age   2  
Patient’s Gender   2  
Marital Status 1    
# Dependents 1    
Occupation   2  
Primary Language   1  
Living Arrangements 1    
CYFD Custody (Y/N), Social Worker Name and Phone   1  
JPPO/APPO (Y/N), Probation Officer Name and Phone   1  
Guardian Name and Phone (Minor)   1  
Waiver Status (Enrolled/Waiting List), and Waiver Type 1    
Patient on Long or Short Term Disability 2    
Patient Receiving Worker’s Compensation 1    
Insured’s Name, Address, SSN, Employer   2  
Patient’s Relationship to Insured   2  
Initial Authorization or Continuing 6 1  
Treatment Start/End Dates   8  
Treatment Court Ordered? 1    
Practitioner’s Name, Address, Phone   11  
Practitioner’s ID number and/or License Number   10  
Patient History
Previous MH/SA Treatment? With Same Provider? 2 4 2
Overall efficacy of treatment to date   3 1
History of Substance Abuse 2 5 1
Medical History   3  
Allergies   1  
Diagnosis
DSM-IV Diagnosis 11    
Global Assessment of Functioning (GAF) 10    
Highest GAF in Past Year 8    
Lowest GAF in Past Year 1    
Expected GAF at Discharge 1    
Any Change in Initial Diagnosis 2    
Current/Presenting Problems
Symptoms      
Socially isolated 1    
Unstable/intense relationships 2    
Perfectionist/controlling/rigid 1    
Distrustful/suspicious 1    
Nonconforming to laws/norms 1    
Threatening 1    
Assaultive 1    
Tantrums 1    
Self-mutilating 2   1
Implusive 3   1
Oppositional/defiant 3   1
Work/school inhibition 1    
Agitation 1    
Motor retardation 1    
Hyperactive 3    
Mania     1
Disorganized 1    
Impaired attention/concentration 3   1
Memory impairment 3    
Concrete Thinking 1    
Disorientation to time, place, person or situation 1   1
Impaired judgment 3   1
Lack of insight 1   1
Circumstantiality/tangentiality 1    
Flight of ideas/racing thoughts 1   2
Distorted idiosyncratic thinking 2    
Depressed mood 4   1
Decreased energy 1   1
Withdrawn behavior     1
Dysphoric     1
Apathetic     1
Euthymic     1
Hostile     1
Fearful     1
Restricted     1
Tearfulness     2
Grief 1    
Elated mood 3    
Labile mood 1   2
Low self-esteem/excessive 1    
Hopelessness/Helplessness 2   1
Worthlessness 1   2
Guilt 1   1
Irritability/Inappropriate anger 3   2
Loss of interest/anhedonia 2    
Pain 1   1
Avoidant behavior 1    
Phobia 3   1
Obsessions/compulsions 4   2
Panic attacks 4   1
Somatization 4   1
Generalized anxiety 4   1
Separation anxiety 1    
Hallucinations 3   2
Delusions 3   2
Paranoia 3   1
Ideas of reference 1    
Flashbacks 1    
Depersonalization/dissociation 2   1
Concomitant Medical Condition 1   1
Emotional/Physical/Sexual trauma victim 2   1
Emotional/Physical/Sexual trauma perpetrator 1    
Appetite disturbance 2    
Bizarre behavior 1   1
Conduct problems 1    
Gender issues 1    
Bizarre ideation 1    
Independent living problems 1    
Poor self-care skills 1   1
Dementia     1
ADHD     1
Speech – slow, pressured, monotone, soft, loud, normal     1
Appearance – unkempt, disheveled, unclean, appropriate     1
Substance abuse
Current Substance Abuse 5 1 3
Type of Substance Being Used 1 2  
Continued substance use in spite of knowledge of effects 1    
Mood swings 2    
Inability to control/decrease substance use 2    
Persistent desire for substance/preoccupation 2    
Daily use/morning use/solitary use/secretive use 1    
IV use 1    
Medicinal use 1    
Rapid intake 1    
Excessive consumption/binge 1    
Tolerance of substance 2    
Protecting supply 1    
Passing out/blackouts 1    
Withdrawal 2    
Family history of addiction 1 2 1
Duration and Severity of Symptoms 6 1  
Risk Assessment
Suicide/Homicide 5   3
Family Violence     1
Self-Injury 1   2
Fire Setting     1
High Impulsivity/Aggression     1
Psychosis     1
Non-Compliance with Treatment     1
Lack of Social Support     1
Other Risk Behaviors   2 1
Psychological Testing   1  
Risk of Relapse   1  
Level of Functioning
Relationships – Marriage, Family, Friends 4 2 2
Job/School Performance 4 2 2
Hobbies/Interests/Activities 1    
Physical Health 4 1  
Financial 3    
Activities of Daily Living 2    
Eating Habits 2   1
Weight Loss/Gain and Current Weight 1 1 1
Sleeping Habits 4   1
Sexual Functioning 4   1
Legal Problems 2 1  
Psychiatric/Emotional Problems 1 1  
Behavioral Problems 1 1  
Cognitive Impairment 1 1  
Treatment Information
Requested Procedures/Types of Services 8 1 2
Dates of Treatment, Frequency and Duration 4 7  
Location of Treatment (Office, Clinic, School, Home) 1    
Treatment Approach 1    
Expected Treatment Outcomes/Goals 4 5  
Member Notified/Concurs With Goals? 5 1  
Progress in Treatment 2 3  
Obstacles to Progress   1  
Current Medications 2 8  
Medication Dosage/Frequency 1 7  
Side Effects 3   1
Prescribing Clinician’s Name   3  
Medication Start Date     1
Current Medication Compliance 3 3  
Medication Results in Improvement 1    
Communication with PCP 6 1  
Family/Guardian Involvement and Progress in Treatment 1 2  
Other Family Members in Treatment 1 1  
Patient Receiving Other Treatment or Community Services 4 3 2
Discharge Criteria   2  
Barriers to Discharge (Including Plans to Address)   2  
Living Situation After Discharge   1  
Aftercare Plan   1  
Support Group 1    

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