~OBSERVATION NUMBER
~CLIENT NUMBER
~CLIENT TREATMENT TYPE:
~ABSTRACTOR:
~DATE COMPLETED - MONTH:
~DATE COMPLETED - DAY:
~DATE COMPLETED - YEAR:
~TIME TO COMPLETE:
~ABSTRACT STATUS:
~TRANSMITTAL NUMBER:
~RE-ABSTRACTED:
~QUALITY CONTROL ABSTRACT:
~1. CLIENT RECORD NUMBER:
~2. MONTH OF ADMISSION:
~2. DAY OF ADMISSION:
~2. YEAR OF ADMISSION:
~3. WAIT TIME-ADMISSION INTO PROGRAM:
~4. PLANNED LENGTH OF TREATMENT:
~5. PRIMARY REFERRAL SOURCE:
~6. PRIMARY SOURCE OF PAY FOR TREATMENT:
~7. 2ND SOURCE OF PAY FOR TREATMENT
~8. MONTH TREATMENT BEGAN:
~8. DAY TREATMENT BEGAN:
~8. YEAR TREATMENT BEGAN:
~9. MONTH OF BIRTH:
~9. DAY OF BIRTH:
~9. YEAR OF BIRTH:
~10. AGE AT ADMISSION (IN YEARS):
~11. GENDER:
~12. RACE:
~13. ETHNICITY:
~14. MARITAL STATUS AT ADMISSION:
~15. HAVE CHILD/CHILDREN AT ADMISSION:
~16. LIVING WITH CHILDREN AT ADMISSION:
~17. LIVING ARRANGEMENT AT ADMISSION:
~18. EDUACATION AT ADMISSION:
~19. STUDENT AT ADMISSION:
~20. EMPLOYMENT AT ADMISSION:
~21. USUAL (OR LAST) OCCUPATION:
~22. DWI/DUI ARRESTS PRIOR TO ADMISSION:
~23. OTHER ARRESTS PRIOR TO ADMISSION:
~24. PRISON RECORD PRIOR TO ADMISSION:
~25. DRUG TREATMENT - PROBATION
~26. # ACUTE MEDICAL HOSPITALIZATIONS:
~27. MEDICAL CONDITIONS AT ADMISSION:
~28. PSYCHOLOGICAL DISORDER ADMISSION
~29. DUAL DIAGNOSIS CLIENT AT ADMISSION:
~29A. SPECIFY MENTAL ILLNESS:
~30. PREGNANCY STATUS AT ADMISSION:
~31. PRESENTING PROBLEM AT ADMISSION:
~32. PRINCIPLE TREATMENT FOCUS:
~33. PRIMARY DIAGNOSIS (DSM-III CODE):
~Q33A. SPECIFY PRIMARY DIAGNOSIS:
~Q33B. LIST OTHER DIAGNOSES AND CODES:
~33B. 1ST OTHER DIAGNOSIS (DSM-III):
~33B. 2ND OTHER DIAGNOSIS (DSM-III):
~ OCCUPATIONAL CODE
~ CORRECTIONAL FACILITY
~ ALCOHOL ONLY FACILITY
~ STRATUM SAMPLING FRAME
~ REGION - CENSUS REGION
~ LENGTH OF STAY (DAYS)
~ DURATION OF TREATMENT (DAYS)
~ CALCULATED AGE AT ADMISSION
~ CALCULATED AGE AT DISCHARGE
~ TREATMENT TYPE
~ NUMBER OF DUAL DIAGNOSES AT ADMISSION
~ NUMBER OF DUAL DIAGNOSES AT DISCHARGE
~ NUMBER OF DIAGNOSES AT ADMISSION
~35. COCAINE - EVER USED:
~35. COCAINE - USED IN LAST 30 DAYS:
~35. COCAINE - AGE AT FIRST USE:
~36. CRACK - EVER USED:
~36. CRACK - USED IN LAST 30 DAYS:
~36. CRACK - AGE AT FIRST USE:
~37. HEROIN - EVER USED:
~37. HEROIN - USED IN LAST 30 DAYS:
~37. HEROIN - AGE AT FIRST USE:
~38. NON-TREAT METHADONE - EVER USED:
~38. NON-TREAT METHADONE - USED 30 DAYS:
~38. NON-TREAT METHADONE - AGE 1ST USED
~39. OTHER OPIATES - EVER USED:
~39. OTHER OPIATES - USED LAST 30 DAYS:
~39. OTHER OPIATES - AGE AT FIRST USE:
~40. BARBITURATES - EVER USED:
~40. BARBITURATES - USED LAST 30 DAYS:
~40. BARBITURATES - AGE AT FIRST USE:
~41. BENZODIAZEPINES - EVER USED:
~41. BENZODIAZEPINES - USED 30 DAYS:
~41. BENZODIAZEPINES - AGE AT FIRST USE:
~42. OTHER SEDATIVES - EVER USED:
~42. OTHER SEDATIVES - USED 30 DAYS:
~42. OTHER SEDATIVES - AGE AT FIRST USE:
~43. METHAMPHETAMINES - EVER USED:
~43. METHAMPHETAMINES - USED 30 DAYS:
~43. METHAMPHETAMINES - AGE AT 1ST USE:
~44. OTHER AMPHETAMINES - EVER USED:
~44. OTHER AMPHETAMINES - USED 30 DAYS:
~44. OTHER AMPHETAMINES-AGE AT 1ST USE:
~45. MARIJUANA/HASHISH/THC - EVER USED:
~45. MARIJUANA/HASH/THC - USED 30 DAYS
~45. MARIJUANA/HASHISH/THC-AGE 1ST USE:
~46. PCP/LSD - EVER USED:
~46. PCP/LSD - USED IN LAST 30 DAYS:
~46. PCP/LSD - AGE AT FIRST USE:
~47. OTHER HALLUCINOGENS - EVER USED:
~47. OTHER HALLUCINOGENS - USED 30 DAYS:
~47. OTHER HALLUCINOGENS - AGE 1ST USE:
~48. INHALANTS - EVER USED:
~48. INHALANTS - USED IN LAST 30 DAYS:
~48. INHALANTS - AGE AT FIRST USE:
~49. OVER-THE-COUNTER - EVER USED:
~49. OVER-THE-COUNTER - USED 30 DAYS:
~49. OVER-THE-COUNTER - AGE AT 1ST USE:
~50. ALCOHOL - EVER USED:
~50. ALCOHOL - USED IN LAST 30 DAYS:
~50. ALCOHOL - AGE AT FIRST USE:
~51. OTHER (SPECIFY) - EVER USED:
~51. OTHER (SPECIFY) - USED 30 DAYS:
~51. OTHER (SPECIFY) - AGE AT FIRST USE:
~52. DRUG OF CHOICE AT ADMISSION:
~53A. INTRAVENOUS DRUG USER EVER:
~53B. INTRAVENOUS DRUG USER AT ADM:
~53C. FREQUENCY OF INTRAVENOUS DRUG USE:
~54. ANY SUBSTANCE ABUSE TESTING:
~54. TYPE OF TEST - FIRST TEST:
~54. TYPE OF TEST - LAST TEST:
~54. MONTH OF FIRST TEST RESULT:
~54. DAY OF FIRST TEST RESULT:
~54. YEAR OF FIRST TEST RESULT:
~54. MONTH OF LAST TEST RESULT:
~54. DAY OF LAST TEST RESULT:
~54. YEAR OF LAST TEST RESULT:
~54A. COCAINE/CRACK FIRST TEST RESULT:
~54A. COCAINE/CRACK LAST TEST RESULT:
~54B. HEROIN FIRST TEST RESULT:
~54B. HEROIN LAST TEST RESULT:
~54C. NON-TREAT METHADONE FIRST RESULT:
~54C. NON-TREAT METHADONE LAST RESULT:
~54D. OTHER OPIATES FIRST TEST RESULT:
~54D. OTHER OPIATES LAST TEST RESULT:
~54E. BARBITURATES FIRST TEST RESULT:
~54E. BARBITURATES LAST TEST RESULT:
~54F. BENZODIAZEPINES FIRST TEST RESULT:
~54F. BENZODIAZEPINES LAST TEST RESULT:
~54G. OTHER SEDATIVES FIRST TEST RESULT:
~54G. OTHER SEDATIVES LAST TEST RESULT:
~54H. METHAMPHETAMINES FIRST TEST
~54H. METHAMPHETAMINES LAST TEST RESULT:
~54I. OTHER AMPHETAMINES FIRST RESULT:
~54I. OTHER AMPHETAMINES LAST RESULT:
~54J. MARIJUANA FIRST TEST RESULT:
~54J. MARIJUANA LAST TEST RESULT:
~54K. PCP/LSD FIRST TEST RESULT:
~54K. PCP/LSD LAST TEST RESULT:
~54L. OTHER HALLUCINOGENS FIRST RESULT:
~54L. OTHER HALLUCINOGENS LAST RESULT:
~54M. INHALANTS FIRST TEST RESULT:
~54M. INHALANTS LAST TEST RESULT:
~54N. ALCOHOL FIRST TEST RESULT:
~54N. ALCOHOL LAST TEST RESULT:
~54O. OTHER SUBSTANCE FIRST TEST RESULT:
~54O. OTHER SUBSTANCE LAST TEST RESULT:
~55. TOTAL NUMBER OF TESTS IN TREATMENT:
~56. TOTAL NUMBER OF POSITIVE TESTS:
~57. NUMBER OF TREATMENT EPISODES:
~57A. # OF YRS TREATMENT EPISODES
~58. PAST TREATMENT EPISODES IN 12 MTHS:
~58. NUMBER OF ENTRIES IN TABLE:
~58A. REASON FOR TREATMENT - PRIMARY:
~58A. REASON FOR TREATMENT - SECONDARY:
~58A. FACILITY:
~58A. REASON FOR DISCHARGE:
~58B. REASON FOR TREATMENT - PRIMARY:
~58B. REASON FOR TREATMENT - SECONDARY:
~58B. FACILITY:
~58B. REASON FOR DISCHARGE:
~58C. REASON FOR TREATMENT - PRIMARY:
~58C. REASON FOR TREATMENT - SECONDARY:
~58C. FACILITY:
~58C. REASON FOR DISCHARGE:
~58D. REASON FOR TREATMENT - PRIMARY:
~58D. REASON FOR TREATMENT - SECONDARY:
~58D. FACILITY:
~58D. REASON FOR DISCHARGE:
~58E. REASON FOR TREATMENT - PRIMARY:
~58E. REASON FOR TREATMENT - SECONDARY:
~58E. FACILITY:
~58E. REASON FOR DISCHARGE:
~58F. REASON FOR TREATMENT - PRIMARY:
~58F. REASON FOR TREATMENT - SECONDARY:
~58F. FACILITY:
~58F. REASON FOR DISCHARGE:
~58G. REASON FOR TREATMENT - PRIMARY:
~58G. REASON FOR TREATMENT - SECONDARY:
~58G. FACILITY:
~58G. REASON FOR DISCHARGE:
~58H. REASON FOR TREATMENT - PRIMARY:
~58H. REASON FOR TREATMENT - SECONDARY:
~58H. FACILITY:
~58H. REASON FOR DISCHARGE:
~58I. REASON FOR TREATMENT - PRIMARY:
~58I. REASON FOR TREATMENT - SECONDARY:
~58I. FACILITY:
~58I. REASON FOR DISCHARGE:
~58J. REASON FOR TREATMENT - PRIMARY:
~58J. REASON FOR TREATMENT - SECONDARY:
~58J. FACILITY:
~58J. REASON FOR DISCHARGE:
~59. INDIVIDUAL COUNSELING - GIVEN:
~59. INDIVIDUAL COUNSELING - FACILITY:
~59. INDIVID COUNSELING - # ENCOUNTERS:
~60. GROUP COUNSELING - SERVICE GIVEN:
~60. GROUP COUNSELING - FACILITY:
~60. GROUP COUNSELING - # OF ENCOUNTERS:
~61. FAMILY COUNSELING - SERVICE GIVEN:
~61. FAMILY COUNSELING - FACILITY:
~61. FAMILY COUNSELING - # ENCOUNTERS
~62. DRUG EDUCATION - SERVICE GIVEN:
~62. DRUG EDUCATION - FACILITY:
~62. DRUG EDUCATION - # OF ENCOUNTERS:
~63. EMPLOYMENT COUNSELING - GIVEN:
~63. EMPLOYMENT COUNSELING - FACILITY:
~64. JOB TRAINING - SERVICE GIVEN:
~64. JOB TRAINING - FACILITY:
~65. EDUCATIONAL CLASSES - GIVEN:
~65. EDUCATIONAL CLASSES - FACILITY:
~66. DETOXIFICATION - SERVICE GIVEN:
~66. DETOXIFICATION - FACILITY:
~67. ACTIVITY GROUPS - SERVICE GIVEN:
~67. ACTIVITY GROUPS - FACILITY:
~68. SELF-HELP GROUPS - SERVICE GIVEN:
~68. SELF-HELP GROUPS - FACILITY:
~69. DAY CARE - SERVICE GIVEN:
~69. DAY CARE - FACILITY:
~70. MEDICATIONS PRESCRIBED - TREATMENT:
~70A. MEDICATIONS SPECIFIED:
~71. PHYSICIAN NOTES AT ADMISSION:
~72. PHYSICIAN NOTES AT DISCHARGE:
~73. PHYSICIAN NOTES AT ANY OTHER TIME:
~74. METHADONE GIVEN DURING TREATMENT:
~74A. FIRST TREATMENT - MONTH:
~74A. FIRST TREATMENT - DAY:
~74A. FIRST TREATMENT - YEAR:
~74A. 1ST TREATMENT - TOTAL DAILY DOSE:
~74A. FIRST TREATMENT - GIVEN DOSE:
~74A. FIRST TREATMENT - # OF TIMES/DAY:
~74A. FIRST TREATMENT - PLACE:
~74B. LAST TREATMENT - MONTH:
~74B. LAST TREATMENT - DAY:
~74B. LAST TREATMENT - YEAR:
~74B. LAST TREATMENT - TOTAL DAILY DOSE:
~74B. LAST TREATMENT - GIVEN DOSE:
~74B. LAST TREATMENT - # OF TIMES/DAY:
~74B. LAST TREATMENT - PLACE:
~75. METHADONE SUPPLY TAKEN HOME:
~76. REASON FOR DISCHARGE:
~76A. MONTH OF DEATH:
~76A. DAY OF DEATH:
~76A. YEAR OF DEATH:
~76B. SPECIFY REASON:
~77. MONTH OF DISCHARGE:
~77. DAY OF DISCHARGE:
~77. YEAR OF DISCHARGE:
~78. MONTH OF LAST TREATMENT:
~78. DAY OF LAST TREATMENT:
~78. YEAR OF LAST TREATMENT:
~79. DUAL DIAGNOSIS CLIENT AT DISCHARGE:
~79A. SPECIFY MENTAL ILLNESS:
~80. AFTER-CARE PLAN STATED IN RECORD:
~81. SERVICES IN AFTER-CARE PLAN:
~81A. INDIVIDUAL COUNSELING:
~81B. GROUP COUNSELING:
~81C. FAMILY COUNSELING:
~81D. EDUCATIONAL CLASSES:
~81E. EMPLOYMENT COUNSELING:
~81F. JOB TRAINING:
~81G. ACTIVITY GROUPS:
~81H. SELF-HELP GROUPS(AA/NA):
~81I. ALUMNI GROUP/REUNION:
~81J. OTHER (SPECIFY):
~82. TREATMENT TO WHICH CLIENT REFERRED
~83. BILLED CHARGES FOR THIS TREATMENT:
~83A. FUNDED SLOT?
~84. CHARGES RECORDED REFER TO:
~84. SPECIFY PERCENTAGE OF FULL BILLED:
~85. COMMENTS:
~BATCH NUMBER
~1ST DX - ICD-9-CM CODE @ ADM
~2ND DX - ICD-9-CM CODE @ ADM
~3RD DX - ICD-9-CM CODE @ ADM
~4TH DX - ICD-9-CM CODE @ ADM
~PRIMARY DX - ICD-9-CM CODE @ ADM
~1ST OTHER DX - ICD-9-CM CODE @ ADM
~2ND OTHER DX - ICD-9-CM CODE @ ADM
~3RD OTHER DX - ICD-9-CM CODE @ ADM
~4TH OTHER DX - ICD-9-CM CODE @ ADM
~5TH OTHER DX - ICD-9-CM CODE @ ADM
~6TH OTHER DX - ICD-9-CM CODE @ ADM
~1ST DUALDX - ICD-9-CM CODE @ DISCHRG
~2ND DUAL DX - ICD-9-CM CODE @ DISCHRG
~3RD DUAL DX - ICD-9-CM CODE @ DISCHRG
~4TH DUAL DX - ICD-9-CM CODE @ DISCHRG
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