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The Ohio Behavioral Discharge Form plays a crucial role in documenting the transition of clients from behavioral health services. This comprehensive form captures essential information such as the client's unique identification details, including their name, date of birth, and unique client ID. It outlines the reasons for discharge, which can range from successful completion of treatment to involuntary discharge due to non-participation or rule violations. The form also records the client's educational background, living arrangements, and employment status, providing a holistic view of their circumstances. Additionally, it delves into the client's substance use history, including drug of choice and frequency of use, as well as any co-occurring physical health conditions. By collecting this information, the Ohio Behavioral Discharge Form ensures that all relevant data is available for future care and support, facilitating a smoother transition for clients into their next phase of recovery or treatment.

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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

 

Unknown

 

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

 

Unknown

 

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

 

Not Enrolled

 

Engaged in Residential/Hospitalization

 

Crisis Care

 

Other: Literacy,

Unknown

 

Other

 

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

 

 

 

Other Amphetamines

 

 

|

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

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

 

 

 

 

 

 

Unknown

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Other

 

following since admission or last update?

 

 

 

 

 

 

 

 

 

 

Forensic Status

 

 

Inhalation

Unknown

 

 

 

 

 

 

 

 

 

 

 

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

Unknown

 

Multi-Systemic Therapy (MST)

 

 

 

 

 

 

Functional Family Therapy

 

Marijuana/Hashish

 

 

Does the client use tobacco products?

 

 

 

Heroin

 

 

 

Yes

No

Don’t Know

 

Intensive Home-based Therapy (IBHT)

 

Drug of Choice (Secondary)

 

 

Drug of Choice (Tertiary)

 

 

 

 

 

 

 

 

Alcohol

 

 

 

Alcohol

 

 

 

 

Cocaine/Crack

 

 

Cocaine/Crack

 

 

Marijuana/Hashish

 

 

Marijuana/Hashish

 

 

Heroin

 

 

 

Heroin

 

 

 

 

Non-prescription Methadone

 

Non-prescription Methadone

 

Other Opiates and Synthetics

 

Other Opiates and Synthetics

 

PCP

 

 

 

PCP

 

 

 

 

Other Hallucinogens

 

 

Other Hallucinogens

 

 

Methamphetamines

 

 

Methamphetamines

 

 

Other Amphetamines

 

 

Other Amphetamines

 

 

Other Stimulants

 

 

Other Stimulants

 

 

Benzodiazepines

 

 

Benzodiazepines

 

 

Other Non-Barbiturate Tranquilizers

 

Other Non-Barbiturate Tranquilizers

 

Barbiturates

 

 

Barbiturates

 

 

Other Non-Barb. Sedatives/Hypnotics

 

Other Non-Barb. Sedatives/Hypnotics

 

Inhalants

 

 

 

Inhalants

 

 

 

 

Over-the-Counter Medications

 

Over-the-Counter Medications

 

Nicotine

 

 

 

Nicotine

 

 

 

 

Other Medications

 

 

Other Medications

 

 

Unknown

 

 

Unknown

 

 

None

 

 

 

None

 

 

 

Frequency of Use

 

Frequency of Use

 

 

No use Past Mo

1 3 X Past Week

 

No use Past Mo

1 3 X Past Week

 

1 2 X in Past Mo

3 6 X Past Week

 

1 2 X in Past Mo

3 6 X Past Week

 

Daily

 

Unknown

 

Daily

 

 

Unknown

Route of Administration

 

Route of Administration

 

 

Oral

 

Injection

 

Oral

 

 

Injection

 

Smoking

 

Other

 

Smoking

 

 

Other

 

Inhalation

 

Unknown

 

Inhalation

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

Age of First Use – First

 

 

 

Age of First Use – First

|

 

Intoxication

 

|

 

Intoxication

 

 

 

 

 

 

 

 

 

Secondary AOD Code

 

 

Tertiary AOD Code

 

 

 

 

 

 

 

 

 

 

 

 

Form Specifications

Fact Name Description
Purpose The Ohio Behavioral Discharge Form is designed to document the discharge of clients from behavioral health services, capturing essential details about their treatment and outcomes.
Governing Law This form is governed by Ohio Revised Code Sections 5119.01 to 5119.99, which outline the standards for mental health and addiction services.
Client Information The form requires specific client information, including the unique client ID, name, date of birth, and discharge date to ensure accurate record-keeping.
Discharge Reasons Various discharge reasons are provided, such as successful completion, involuntary discharge, or referral to another service, allowing for comprehensive tracking of client progress.
Data Collection The form collects data on client demographics, treatment history, and health conditions, which is crucial for ongoing care and statistical analysis of service effectiveness.

Ohio Behavioral Discharge: Usage Guidelines

Completing the Ohio Behavioral Discharge form is an essential step in ensuring that all necessary information is documented accurately. This form collects vital details about the client's discharge from services, which will be used for future reference and planning. Follow the steps below to fill out the form correctly.

  1. Provider Information: Enter the Unique Provider Number and the Episode Number at the top of the form.
  2. Client Identification: Fill in the client's name (first and last), Unique Client ID, and Date of Birth (format: mm/dd/yyyy).
  3. Service Dates: Record the Last Date of Service and the Discharge Date.
  4. Discharge Reason: Select the appropriate discharge reason from the provided options, marking only one.
  5. Education Type: If applicable, choose the Education Type for K-12 clients.
  6. Income/Support: Indicate the Primary Income/Support source by selecting one option.
  7. Provider Preference: Answer whether the client chose another provider due to religious preference (Yes or No).
  8. Educational Background: Select the Highest Educational Level Completed by the client.
  9. Employment Status: Choose the client's Employment Status from the options provided.
  10. Living Arrangements: Select the current Living Arrangements of the client.
  11. Drug of Choice: Indicate the client's Drug of Choice and provide relevant details about frequency and route of administration.
  12. Health Conditions: Select any relevant Physical Health Conditions and provide Diagnosis Codes as needed.
  13. Special Populations: Identify any Special Populations that apply to the client.
  14. Health Care Utilization: Document any recent Hospital Admissions or Emergency Room Visits.
  15. Evidence Based Practices: Indicate if the client received any Evidence Based Practices since admission.
  16. Self-Help Programs: Note the frequency of attendance at self-help programs in the 30 days prior to discharge.
  17. Drug of Choice (Secondary and Tertiary): If applicable, fill in the Secondary and Tertiary Drug of Choice.

After completing the form, review all entries for accuracy. Ensure that all required fields are filled out and that the information reflects the client's situation accurately. This will help in providing continuity of care and support for the client moving forward.

Your Questions, Answered

What is the Ohio Behavioral Discharge form?

The Ohio Behavioral Discharge form is a document used to record the details of a client’s discharge from behavioral health services. It captures essential information, including the client's unique identifiers, discharge reasons, and relevant health and social data. This form is crucial for ensuring that all parties involved in the client’s care have a clear understanding of their treatment journey and discharge status.

Who needs to fill out the Ohio Behavioral Discharge form?

The form must be completed by the provider or staff member responsible for the client's care at the time of discharge. This includes therapists, case managers, or any authorized personnel who have been involved in the client's treatment process. Accurate completion is vital to ensure continuity of care and proper documentation.

What information is required on the form?

Essential information includes the client's name, unique client ID, date of birth, last date of service, and discharge date. Additionally, the form requires the reason for discharge, which can range from successful completion to involuntary discharge due to non-participation. Other sections address the client's educational background, living arrangements, and health conditions.

What are the possible discharge reasons listed on the form?

The form includes various discharge reasons such as successful completion of treatment, assessment and evaluation only, voluntary departure against staff advice, involuntary discharge due to rule violations, and referrals to other services. Each reason is critical for understanding the client's progress and future needs.

How does the form address the client's educational background?

The form includes sections for recording the highest educational level completed by the client and their current educational enrollment status. This information helps providers understand the client’s background and tailor future services accordingly.

What is the significance of the drug of choice section?

This section allows providers to document the client’s primary, secondary, and tertiary substances of abuse. Understanding the client's drug history is crucial for developing effective treatment plans and ensuring appropriate follow-up care.

How is the form used for future service planning?

The information collected on the Ohio Behavioral Discharge form is instrumental in planning future services for the client. By capturing discharge reasons, health conditions, and social determinants, providers can make informed decisions about referrals and ongoing support that may be necessary for the client’s recovery journey.

What happens to the form after it is completed?

Once the form is completed, it is typically stored in the client's medical record. It may also be shared with relevant stakeholders involved in the client's care, such as other treatment facilities or support services, to ensure a smooth transition and continuity of care.

Where can I obtain the Ohio Behavioral Discharge form?

The Ohio Behavioral Discharge form can usually be obtained from the Ohio Department of Mental Health and Addiction Services website or directly from behavioral health providers. It is important to ensure that you have the most current version of the form to comply with state requirements.

Common mistakes

  1. Incomplete Personal Information: Many individuals forget to fill in essential personal details such as their full name, date of birth, or unique client ID. This information is crucial for proper identification and processing.

  2. Incorrect Discharge Reason: Selecting the wrong discharge reason can lead to misunderstandings. It is important to choose the option that accurately reflects the client's situation, whether it was a successful completion or an involuntary discharge.

  3. Missing Signatures: Failing to sign the form can cause delays. Both the client and the provider may need to sign to validate the discharge.

  4. Neglecting to Specify Educational Status: Not indicating the highest educational level completed can affect the client’s future service eligibility. This detail is vital for understanding the client's background.

  5. Omitting Health Information: Some people overlook the section regarding physical health conditions. Providing accurate health information is essential for a comprehensive understanding of the client’s needs.

  6. Inaccurate Frequency of Use: Misreporting the frequency of substance use can lead to inappropriate treatment recommendations. Accurate reporting helps in tailoring future services effectively.

  7. Ignoring Special Populations Section: Failing to select relevant special populations can result in missed opportunities for additional support services. This section is important for identifying specific needs.

Documents used along the form

The Ohio Behavioral Discharge form is a crucial document used in the context of mental health and substance abuse treatment. Alongside this form, several other documents are often utilized to ensure comprehensive patient care and proper record-keeping. Below is a list of four such documents, each playing a significant role in the discharge process.

  • Client Treatment Plan: This document outlines the goals and objectives for a client’s treatment. It details the strategies and interventions that will be employed to achieve these goals, providing a roadmap for both the client and the treatment team.
  • Progress Notes: These notes are recorded by healthcare providers during each session. They document the client’s progress, any challenges faced, and adjustments made to the treatment plan. Progress notes are essential for tracking the client’s journey and informing future care decisions.
  • Referral Form: When a client requires services beyond what the current provider can offer, a referral form is used. This document facilitates the transfer of necessary information to the new provider, ensuring continuity of care and that the client receives appropriate support.
  • Aftercare Plan: An aftercare plan outlines the steps a client should take following discharge. It may include recommendations for follow-up appointments, support groups, and other resources that can aid in the client’s ongoing recovery and well-being.

Each of these documents serves a distinct purpose in the discharge process, contributing to a holistic approach to client care. Together, they help ensure that individuals transitioning out of treatment continue to receive the support they need for successful outcomes.

Similar forms

  • Discharge Summary Form: Similar to the Ohio Behavioral Discharge form, a discharge summary outlines a patient's treatment history, progress, and the reasons for discharge. Both documents provide a comprehensive overview of the client's journey and any recommendations for future care.

  • Client Assessment Form: This form is used to evaluate a client's needs and progress during treatment. Like the Ohio Behavioral Discharge form, it collects detailed information about the client's circumstances, including their treatment goals and outcomes.

  • Transfer Summary Form: When a client is transferred to another facility, this form documents their treatment history and any ongoing needs. It shares similarities with the Ohio Behavioral Discharge form in that both aim to ensure continuity of care and provide essential information to the receiving provider.

  • Treatment Plan Review: This document outlines the goals and objectives set for a client during their treatment. It is similar to the Ohio Behavioral Discharge form in that it assesses progress and may include recommendations for future treatment or referrals.

  • Follow-Up Care Plan: After discharge, a follow-up care plan helps clients transition back into their daily lives. This document is akin to the Ohio Behavioral Discharge form as both emphasize the importance of ongoing support and resources for the client.

  • Informed Consent Form: This form ensures that clients understand their treatment options and agree to the proposed services. Both the informed consent form and the Ohio Behavioral Discharge form prioritize client autonomy and informed decision-making throughout the treatment process.

Dos and Don'ts

When filling out the Ohio Behavioral Discharge form, attention to detail is crucial. Here are some important dos and don'ts to ensure accuracy and completeness.

  • Do verify all personal information, including the client's name and date of birth, to avoid errors.
  • Do select the appropriate discharge reason that accurately reflects the client's situation.
  • Do include all relevant diagnosis codes to provide a clear picture of the client's health status.
  • Do ensure that the discharge date is correctly noted, as this is essential for record-keeping.
  • Don't leave any sections blank unless specifically instructed; incomplete forms may lead to delays.
  • Don't use abbreviations or shorthand that may confuse the reader; clarity is key.

Misconceptions

Misconceptions about the Ohio Behavioral Discharge form can lead to confusion and misinterpretation. Here are eight common myths, along with clarifications to help you understand the purpose and use of this important document.

  • It's only for clients who completed treatment successfully. Many people believe that the form is only used for successful discharges. In reality, it captures various discharge reasons, including involuntary discharges and referrals to other services.
  • All discharges are the same. Each discharge reason is unique and documented differently. The form includes options for satisfactory and unsatisfactory progress, which reflect the client's journey and outcomes.
  • The form is only for mental health services. While it is often associated with mental health, the Ohio Behavioral Discharge form is applicable to various behavioral health services, including substance use treatment.
  • Only the client’s final status is recorded. The form provides a comprehensive overview of the client's journey, including previous assessments, progress notes, and discharge reasons, ensuring a holistic view of their care.
  • Discharge reasons are not significant. Each reason for discharge carries weight. They help providers understand patterns, improve services, and ensure that clients receive appropriate follow-up care.
  • The form is not useful for future care. The information documented in this form can be invaluable for future providers. It gives them insights into the client’s history, challenges, and treatment preferences.
  • It's a one-time document. The Ohio Behavioral Discharge form is not static. It can be updated as the client's situation changes or as they engage with new services, ensuring that it remains relevant.
  • Clients don’t have any input in the discharge process. Clients are encouraged to be involved in their discharge planning. Their feedback and preferences can influence the documentation and future care options.

Understanding these misconceptions can help clients, families, and providers navigate the discharge process more effectively. Clear communication and accurate documentation are essential in supporting individuals as they transition from one phase of care to another.

Key takeaways

When filling out and using the Ohio Behavioral Discharge form, several key points should be kept in mind to ensure accurate and effective documentation.

  • Complete All Required Fields: Ensure that all mandatory sections, such as Unique Provider Number, Episode Number, and Client Information, are filled out completely. Missing information can delay processing.
  • Choose the Correct Discharge Reason: Select the appropriate discharge reason from the provided options. This helps in understanding the client's journey and future needs.
  • Document Client Progress: Indicate whether the client made satisfactory or unsatisfactory progress. This information is crucial for future service providers.
  • Provide Accurate Diagnosis Codes: Clearly state the primary, secondary, and tertiary diagnosis codes. Accurate coding is essential for insurance and treatment continuity.
  • Utilize the Client’s Drug of Choice: Record the primary, secondary, and tertiary drug of choice accurately. This helps in tailoring future treatment plans.
  • Review Before Submission: Double-check all entries for accuracy and completeness. A thorough review can prevent errors that might affect the client's care.

These takeaways can help streamline the discharge process and ensure that clients receive the appropriate follow-up care they need.