PIP Table of Contents
AFTERCARE APPOINTMENT ...... Page 3
AGE ...... Page 4
BROUGHT BY ...... Page 5
CASE COORDINATOR ...... Page 6
COMMENTS, MISCELLANEOUS ...... Page 7
COMMUNITY LIVING NEEDS ...... Page 8
CRIMINAL CHARGES RELATING TO ADMISSION - CODES ...... Page 9
CRIMINAL CHARGES RELATING TO ADMISSION - COUNTS ...... Page 10
CUSTODY OF PATIENT ...... Page 11
DATE CHART ANALYZED BY MEDICAL RECORDS ...... Page 12
DATE CHART ASSEMBLED BY MEDICAL RECORDS ...... Page 13
DATE CHART COMPLETE ...... Page 14
DATE CHART PLACED IN DOCTORS FILES FOR SIGNATURE ...... Page 15
DATE CHART RECEIVED BY MEDICAL RECORDS ...... Page 16
DATE D/C DIAGNOSIS WAS CODED ...... Page 17
DATE D/C SUMMARY DICTATED ...... Page 18
DATE D/C SUMMARY RECEIVED ...... Page 19
DATE D/C SUMMARY SIGNED ...... Page 20
DATE D/C SUMMARY TYPED ...... Page 21
DATE LEGAL STATUS EXPIRES ...... Page 22
DATE OF ADMISSION ...... Page 23
DATE OF BIRTH ...... Page 24
DATE OF DISCHARGE ...... Page 25
DATE OF LAST DISCHARGE FROM FACILITY ...... Page 26
DATE OF LAST MODIFICATION OF RECORD ...... Page 27
DATE OF LAST TREATMENT TEAM REVIEW/STAFFING ...... Page 28 DATE RECORD CREATED ...... Page 29
DATE RELEASE OF INFORMATION SIGNED ...... Page 30
DEVELOPMENTALLY DISABLED ...... Page 31
DIAGNOSIS, AXIS I, A - D ...... Page 32
DIAGNOSIS, AXIS II, A - D ...... Page 33
DIAGNOSIS, AXIS III, A - D ...... Page 34
DIAGN OSIS, AXIS IV ...... Page 35
DIAGNOSIS, AXIS V ...... Page 36
DIAGNOSIS, PRIMARY, ADMISSION ...... Page 37
DIAGNOSIS, PRIMARY, DISCHARGE ...... Page 38
DIAGNOSIS, PRIMARY, TREATING ...... Page 39
DIAGNOSIS, PROVISIONAL CO DE, LABELS 1 - 2 ...... Page 40
DIAGNOSIS, PROVISIONAL CODE, LABEL 3 ...... Page 41
DISCHARGE BARRIERS ...... Page 42
DISPOSITION ...... Page 43
DRUG ...... Page 44
DRUG, AGE AT FIRST USE ...... Page 46
DRUG, FREQUENCY ...... Page 47
DRUG, METHOD ...... Page 48
EDUCATION LEVEL ...... Page 49
EMERGENCY CONTACT, ADDRESS ...... Page 50
EMERGENCY CONTACT, CITY ...... Page 51
EMERGENCY CONTACT, NAME ...... Page 52
EMERGENCY CONTACT, PHONE NUMBER ...... Page 53
EMERG ENCY CO NTAC T, RELATIO NSHIP ...... Page 54
EMERGENCY CONTACT, STATE ...... Page 55
EMERGENCY CONTACT, ZIP CODE ...... Page 56 ETHNICITY ...... Page 57
FACILITY CODE ...... Page 58
FACILITY IDENTIFIER ...... Page 59
FACILITY IDENTIFIER, EARL K. LONG ...... Page 60
FATHER, ADDRESS ...... Page 61
FATHER, CITY ...... Page 62
FATHE R, NAM E ...... Page 63
FATHER, OCCUPATION ...... Page 64
FATHER, PHONE NUMBER ...... Page 65
FATHER, STATE ...... Page 66
FATHER, ZIP CODE ...... Page 67
HANDICAPS ...... Page 68
HOSPITAL NUMBER ...... Page 70
HOS PITAL NUM BER, PREF IX ...... Page 71
HOUSEHOLD COMPOSITION ...... Page 72
HOUSING ...... Page 73
INCOME, PRINCIPAL SOURCE OF ...... Page 74
INCOME, TOTAL FAMILY ...... Page 75
JUDGE ...... Page 76
LAST SCHOOL ATTENDED ...... Page 77
LEGAL GUARDIAN, ADDRESS ...... Page 78
LEGAL GUARDIAN, CITY ...... Page 79
LEGAL GUARDIAN, NAM E ...... Page 80
LEGAL GUARDIAN, PHONE NUMBER ...... Page 81
LEGAL GU ARDIAN , RELAT IONSHIP ...... Page 82
LEGAL GUARDIAN, STATE ...... Page 83
LEGAL GUARDIAN, ZIP CODE ...... Page 84 LENGTH OF MENTAL DISABILITY ...... Page 85
LENGTH OF STAY, CURRENT ...... Page 86
LENGTH OF STAY, EXPECTED ...... Page 87
LIVING ARRANGEMENT ...... Page 88
MED ICAID, ELIGIBILITY BEGAN ...... Page 89
MEDICAID, ELIGIBILITY ENDED ...... Page 90
MEDICAID, NUMBER ...... Page 91
MED ICARE, ELIGIBILITY BEG AN ...... Page 92
MEDICARE, ELIGIBILITY ENDED ...... Page 93
MEDICARE, NUMBER ...... Page 94
MOTHER, ADDRESS ...... Page 95
MOTHER, CITY ...... Page 96
MOTHER, NAME ...... Page 97
MOTHER, OCCUPATION ...... Page 98
MOTHER, PHONE NUMBER ...... Page 99
MOTHER, STATE ...... Page 100
MOTHER, ZIP CODE ...... Page 101
NUMBER OF DEPENDENTS ...... Page 102
NUMBER OF DRUG TREATMENT EPISODES ...... Page 103
NUMBER OF PREVIOUS ADMISSIONS TO THIS FACILITY ...... Page 104
PAPERWORK COMPLETED FOR ADMISSION ...... Page 105
PARISH OF LEGAL COMMITMENT ...... Page 106
PARISH OF RESIDENCE ...... Page 107
PATIENT, ADDRESS ...... Page 108
PATIENT, BIRTHPLACE ...... Page 109
PATIENT, CITY ...... Page 110
PATIENT, NAME, FIRST ...... Page 111 PATIENT, NAME, LAST ...... Page 112
PATIENT, NAM E, MIDD LE INITIAL ...... Page 113
PATIENT, PHONE NUMBER ...... Page 114
PATIENT, STATE ...... Page 115
PATIENT, ZIP CODE ...... Page 116
PAYMENT, SOURCE OF ...... Page 117
PERSON HANDLING CHART ...... Page 119
PHYSICIAN, ADMITTING ...... Page 120
PHYSICIAN, DISCHARGING ...... Page 121
PHYSICIAN, TREATING/ATTENDING ...... Page 122
PREGNANT ...... Page 123
PRES ENTING PROB LEM S ON ADMISSION - ABU SE/RAP E VICT IM ...... Page 124
PRESENTING PROBLEMS ON ADMISSION - ALCOHOL USE ...... Page 125
PRESENTING PROBLEMS ON ADMISSION - CRIMINAL INVOLVEMENT Index ...... Page 126
PRESENTING PROBLEMS ON ADMISSION - DRUG USE ...... Page 127
PRESENTING PROBLEMS ON ADMISSION - EATING DISORDER ...... Page 128
PRESENTING PROBLEMS ON ADMISSION - GRAVELY DISABLED ...... Page 129
PRESENTING PROBLEMS ON ADMISSION - MARITAL PROBLEM ...... Page 130
PRES ENTING PROB LEM S ON ADMISSION - MEDICAL/SOMAT IC ...... Page 131
PRESENTING PROBLEMS ON ADMISSION - MOOD DISORDER ...... Page 132
PRESENTING PROBLEMS ON ADMISSION - PROBLEMS W/ DAILY ACTIVITIES ...... Page 133
PRESENTING PROBLEMS ON ADMISSION - RUNAWAY BEHAVIOR ...... Page 135
PRESENTING PROBLEMS ON ADMISSION - SERIOUS IMPAIRMENT ...... Page 136
PRESENTING PROBLEMS ON ADMISSION - SOCIAL/INTERPERSONAL ...... Page 137
PRESENTING PROBLEMS ON ADMISSION - THOUGHT DISORDER ...... Page 138
PRESENTING PROBLEMS ON ADMISSION - VIOLENT/DANGEROUS TO OTHERS ..... Page 139
PRESENTING PROBLEMS ON ADMISSION - VIOLENT/DANGEROUS TO SELF ...... Page 140 PRIOR MENTAL HEALTH SERVICE, INPATIENT ...... Page 141
PRIOR MENTAL HEALTH SERVICE, NON-INPATIENT ...... Page 142
RACE ...... Page 143
REFERRAL CODE, ADMISSION ...... Page 144
REFERRAL CODE, DISCHARGE ...... Page 146
REFERRAL, UPON ADMISSION ...... Page 148
REFERRAL, UPON DISCHARGE ...... Page 149
REFERRAL, UPON DISCHARGE, OTHER ...... Page 150
REFERRING UNIT, ADMISSION ...... Page 151
RELEASE OF INFORMATION SIGNED ...... Page 152
RELIGION ...... Page 153
SEX ...... Page 154
SOCIAL SECURITY NUMBER ...... Page 155
SPECIAL POPULATION CODES - ACUTE ...... Page 156
SPECIAL POPULATION CODES - SMI/EBD ...... Page 157
SPECIAL POPULATIO N CODES - JU DICIAL ...... Page 160
SPECIAL POPULATION CODES - JUVENILE IN STATE CUSTODY ...... Page 161
STATUS, CURRENT ...... Page 162
STATUS, EMPLOYMENT ...... Page 165
STATU S, LEGAL ...... Page 166
STATU S, MARITAL ...... Page 168
SUPPLEMENTAL SECURITY INCOME ELIGIBLE ...... Page 169
TIME LEGAL STATUS EXPIRES ...... Page 170
TIME OF ADMISSION ...... Page 171
TIME OF DISCHARGE ...... Page 172
TIME RECORD CREATED ...... Page 173
TYPE OF RESIDENCE ...... Page 174 TYPE OF TERMINATION ...... Page 176
UNIT ...... Page 178
UNIT REFERRED TO, INTERVIEW ...... Page 179
UPLO AD TRANSM IT FLAG ...... Page 180
USER DEFINED CHARACTER FIELD #1, #2, #3 ...... Page 181
USER DEFINED DATE FIELD #1, #2, #3 ...... Page 182
USER DEFINED NUMERIC FIELD #1, #2, #3 ...... Page 183
VETERAN'S STATUS ...... Page 184
VETERANS' ADMINISTRATION ELIGIBILITY ...... Page 185
VETERANS' ADMINISTRATION, ELIGIBILITY BEG AN ...... Page 186
VETERANS' ADMINISTRATION, NUMBER ...... Page 187 DESCRI PTI ON: a concise label/text depicting the specific data contained in this field.
DEFI NITION: a brief description of the data element.
FIELD NAME: how a particular unit of data within the data base file is identified. The field name aids the user in accessing specific data and is also useful when preparing reports utilizing external programs such as R & R Report Writer. Changes made for the purpos es of the data warehouse are indicated by parenthetical r eferences (***)
FORMAT: LENGTH = A field' s length determines how much of a parti cular type of data may be stored within that field.
TYPE = The fi eld type is the characteri stic which governs the type of information that can be stored in a particular field.
C = Character Code - These fiel ds may contain any alphanumeric character. The letters A-Z, the numbers 0-9 and any keyboard or ASCII characters are acceptable (PIP only accepts upper case letters).
N = Numeric Code - These fields are used to store numeric data that will be used for calculations. A numeric fiel d will only accept number as data, the + and - signs, and the decimal point.
D = Date Code - This is a field that will accept only dates. Pip stores dates as mm/dd/yyyy, but repor ts can be generated using other formats. Based on t he format select ed, the fi eld can prevent entry of invalid dates such as "13/30/92".
L = Logical Code - These fiel ds contain information that can be stored as a one character field. The data can be represented by "T" meaning true and "F" meaning false, or optionally "Y" for yes and "N" for no. Typicall y they are used to stor e the answer to a question or the result of a condition.
M = Memo Code - This is a field of variable length that contains data in the form of free flowing text.
POPUP = This line contains the name of the Popup database used to insert information into the fiel d, if appropriat e.
ALLOWABLE VALUES: contains defi niti ons of codes that are used in the program or appear in the Popup.
DATA ENTRY PROMPT: the field descri ption/text as di splayed on the computer screen.
HELP TEXT: contains the instructions and procedures regarding the entry of data in a particular fi eld.
Page 1 DATA ENTRY EDITS: are to ensure that only valid codes are entered in this field.
MISSING DATA LOGIC: data is considered missing if t his field is left blank.
INDICATORS: data elements are either suggested for i nclusion i n or required for all pati ent records.
REASON FOR COLLECTI NG: Man y auxiliary level entities make extensive use of patient data to develop typologies. They are interested in this data to assess equity of patient treatment, accessibility to service and the cont inui ty of the treat ment provided to pati ents. To fost er and monitor continuity of care, it is necessary to have a uniform method of identifying clients within a system as well as a method for li nking the information on particular cli ents.
Standardizati on refers to the general acceptance of concepts, quantities, terms and defi nit ions that serve as reference points against which comparisons can be made. The adoption of t hese standards permits communication, judgements and compari sons which allows decisionmakers to make alterations in their servi ce programs intended to improve their approaches to the care of the mentally ill.
The Mental Health Stati stics Improvement Program (MHSIP) is most oft en viewed as the recommended minimum data elements needed to collect and report this inf ormati on. Therefore, PI P utilizes the standards established by MHSIP so that PIP is compatible with and responsive to information requests dependent on these data sets.
Page 2 DESCRI PTI ON: AFTERCARE APPOINTMENT TOC Index
DEFI NITION: The numeric equivalent of the month, day and year of the date of the client's first scheduled mental health follow-up aftercare appointment.
FIELD NAME: AFT_APP
FORMAT: MMDDYYYY Length = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: After Care Appointment: / /
HELP TEXT: The numeric equivalent of the month, day and year of the date of the client's first scheduled aftercare appointment.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Continuity of care
Page 3 DESCRI PTI ON: AGE TOC Index
DEFI NITION: The code which represents the age of the cl ient at admission.
FIELD NAME: AGE
FORMAT: Lengt h = 2 Type = Numeric Popup used = N/A
ALLOWABLE VALUES: This fiel d will not accept an entry.
DATA ENTRY PROMPT: Age:
HELP TEXT: The age of the cli ent is automatically calculated and entered when the user inserts the birth date of the client.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: N/A
INDICATORS: N/A
REASON FOR COLLECTI NG: Demographic
Page 4 DESCRI PTI ON: BROUGHT BY TOC Index
DEFI NITION: The identity (t ext) of the person(s) who brought the client t o the facility.
FIELD NAME: BROUGHT_BY (BRGHT_BY)
FORMAT: Length = 15 Type = Character Popup used = N/A
ALLOWABLE VALUES: N/A
DATA ENTRY PROMPT: Brought by:
HELP TEXT: Enter the name of the per son(s) who brought the cli ent to the facility, i.e., pol ice, parents, etc.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Contact information
Page 5 DESCRI PTI ON: CASE COORDINATOR TOC Index
DEFI NITION: The code which represents the identity of the Case Coordinator to whom this client's case is assigned.
FIELD NAME: CASEMANGR1 (CASEMNG1)
FORMAT: Lengt h = 4 Type = Character Popup us ed = STAFF.DBF
ALLOWABLE VALUES: Refer to popup for values.
DATA ENTRY PROMPT: Case Manager: Client Coordinator:
HELP TEXT: Enter the code to identify the Case Coordinator to whom this client's case is assigned.
Staff Codes: Hospitals and Acute units will be responsible for maintai ning staff ing codes in the popup database file. Members of the Admissi ons Staff, Social Workers, physicians and those staff members who determine the disposition of potent ial clients will each be assigned a four-digit provider code.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: MHSIP, CQI
Page 6 DESCRI PTI ON: COMMENTS, MISCELL ANEOUS TOC Index
DEFI NITION: Miscellaneous comments (text) about the client.
FIELD NAME: COMMENT1, COMMENT2, COMMENT3, COMMENT4
FORMAT: Length = 50 Type = Character Popup used = N/A
ALLOWABLE VALUES: N/A
DATA ENTRY PROMPT: Misc. Comments:
HELP TEXT: Enter (up to four lines of 50 characters or less) any miscel laneous comments about the client.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: N/A
INDICATORS: N/A
REASON FOR COLLECTI NG: Clinical utility
Page 7 DESCRI PTI ON: COMMUNITY LI VING NEEDS TOC Index
DEFI NITION: The codes which represent the needs of the client to live outside the hospital environment.
FIELD NAME: READYNEED1, READYNEED2, READYNEED3, READYNEED4 (RDYNEED1 - RDYNEED4)
FORMAT: Lengt h = 2 Type = Character (Numeric) Popup us ed = NEEDS. DBF
ALLOWABLE VALUES: ? Unknown 01 Housing - No housing is available to this client upon discharge. 02 Entitlements/Benefits - Successful community living will require this client to receive entitlements/benefits. 03 Employment/ Pre-employment - The client will require employment or pre- employment services upon discharge. 04 Educati on/Special Education - The cli ent will require educational and/or special education ref erral upon discharge. 05 Money Management - The client will require assistance with money management upon discharge. 06 Social/ Recreational - The client will require ser vices through a structured social and recreational program upon discharge. 07 Family Living - The client will require a f amily li ving environment upon discharge. 08 Mental Health - The client will require continued mental health services upon discharge. 09 Physical Health - The client will require general medical care servi ces upon discharge. 10 Other Community Living Needs - The client will require other community living needs not listed above. 11 Assessment/Service Plan - The client requires a special assessment and/or service plan for a successful di scharge. 12 Court Order - The cli ent has been mandated to received evaluation and/or treatment as evidenced by a current civil or juvenile court order.
DATA ENTRY PROMPT: Community Living Needs: 1. 2. 3. 4.
HELP TEXT: Select the appropriate codes, (up to 4 fields) for the needs of the client to live outside the hospital environment. Community living needs are client needs which must be met in order to achieve successful community placement.
DATA ENTRY EDITS: 1. Only codes not already enter ed as a Community Li ving Need will be all owed.
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Continuity of care, Expansion of needs and barriers
Page 8 DESCRI PTI ON: CRIMINAL CHARGES RELATING TO ADMISSION - CODES TOC Index
DEFI NITION: The codes which represent those legal charges against the client which ultimately resulted in the client being committed to this hospital.
FIELD NAME: CRIMINAL1, CRIMINAL2, CRIMINAL3, CRIMINAL4 (CRIMIN1 - CRIMIN4)
FORMAT: Length = 12 Type = Character Popup us ed = LEGALCD.DBF
ALLOWABLE VALUES: Refer to popup for values.
DATA ENTRY PROMPT: Criminal Charges relati ng to admission:
HELP TEXT: Admi t - select the code which best represents those legal charges against the cli ent which ultimately resulted in the cli ent being committed to this hospital. Up to four sets of charges may be included for each client. Codes are available in the popup. Enter the number of counts of each legal charge.
Staffing - the codes that were entered on admissi on will automatically be entered.
DATA ENTRY EDITS: 1. Criminal Charges must have at least one entry if Legal Status is " 03 Transfer from Corrections", "11 Judicial -Lockhart vs. Armistead" , "12 Judicial- Not Competent to Proceed", or "13 Judicial-NGBRI".
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Legal tracki ng
Page 9 DESCRI PTI ON: CRIMINAL CHARGES RELATING TO ADMISSI ON - COUNTS TOC Index
DEFI NITION: The numeric equivalent of the counts of each legal charge against the client which ultimately resulted in the client being committed to this hospital.
FIELD NAME: L_CNTS1, L_CNTS2, L_CNTS3, L_CNTS4
FORMAT: Lengt h = 2 Type = Character Popup used = N/A
ALLOWABLE VALUES: N/A
DATA ENTRY PROMPT: Admit A Patient - Criminal Charges: Counts
HELP TEXT: Enter the number of count s of each legal charge against the client which ultimately resulted in the client being committed to this hospital.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Legal tracki ng
Page 10 DESCRI PTI ON: CUSTODY OF PATI ENT TOC Index
DEFI NITION: The identity (text ) of t he person(s) havi ng legal custody over the client, i.e., par ent s, OS worker, etc.
FIELD NAME: CUSTODY
FORMAT: Length = 15 Type = Character Popup used = N/A
ALLOWABLE VALUES: N/A
DATA ENTRY PROMPT: Custody of:
HELP TEXT: Enter the name of the person or persons who have legal custody over the client, i.e., parents, OCS worker, etc.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Contact information
Page 11 DESCRI PTI ON: DATE CHART ANALYZED BY MEDI CAL RECORDS TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date i ndicati ng completi on of chart review for deficiencies.
FIELD NAME: DCANALYSED (DCANALYS)
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Dated Analyzed:
HELP TEXT: Enter the numeri c equivalent of the month, day and year of the date indicating completion of chart review for deficiencies.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 12 DESCRI PTI ON: DATE CHART ASSEMBLED BY MEDI CAL RECORDS TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date indicating chart assembly into discharge record by Medical Records.
FIELD NAME: DCASSEMBLE (DCASSEMB)
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Dated Assembled:
HELP TEXT: Enter the numeric equivalent of the month, day, and year of the date indicating chart assembly into a discharge record by Medical Records.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 13 DESCRI PTI ON: DATE CHART COMPLETE TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of t he date the chart was completed and put into a permanent file by Medical Records.
FIELD NAME: DCPERMFILE (DCPERMFI)
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Date Chart Complete:
HELP TEXT: Enter the numeric equi valent of the month, day, and year of the date the chart was completed and put into a permanent file by Medical Records.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 14 DESCRI PTI ON: DATE CHART PLACED I N DOCTORS FILES FOR SI GNATURE TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date the chart was placed in the Doctor's fil es for review, correction, and/or completi on.
FIELD NAME: DCDOCFILES (DCDOCFIL)
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Date placed in Doctor Files:
HELP TEXT: Enter the numeric equivalent of the month, day, and year of the date the chart was placed in the Doctor' s files for review/correcti on/completion.
DATA ENTRY EDITS N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 15 DESCRI PTI ON: DATE CHART RECEI VED BY MEDI CAL RECORDS TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date the chart was received from unit by Medical Records.
FIELD NAME: DCRECVD
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Recvd By M. Records:
HELP TEXT: Enter the numeric equi valent of the month, day, and year of the date the chart was received from the unit by Medical Records.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 16 DESCRI PTI ON: DATE D/C DIAGNOSIS WAS CODED TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of t he date the discharge diagnoses were coded by Medical Records.
FIELD NAME: DCCODED
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Dated Coded:
HELP TEXT: Enter the numeric equivalent of the month, day and year of the date the discharge diagnoses were coded by Medical Records.
DATA ENTRY EDITS N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 17 DESCRI PTI ON: DATE D/C SUMMARY DICTATED TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date the discharge summary was dictated.
FIELD NAME: DCDICTATED (DCDICTAT)
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Dated Dictated:
HELP TEXT: Enter the numeric equivalent of the month, day and year of the dat e the discharge summary was dictat ed.
DATA ENTRY EDITS N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 18 DESCRI PTI ON: DATE D/C SUMMARY RECEIVED TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date the typed discharge summary was placed on the record for signature by Medical Records.
FIELD NAME: SUMRECVD
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Dated Recei ved:
HELP TEXT: Enter the numeric equivalent of the month, day and year of the dat e the discharge summary was placed on the record for signature by Medical Records.
DATA ENTRY EDITS N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 19 DESCRI PTI ON: DATE D/C SUMMARY SIGNED TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date the discharge summary was signed by the doctor.
FIELD NAME: DC_S IGN
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Dated Summary Signed:
HELP TEXT: Enter the numeric equivalent of the month, day and year of the date the discharge summary was signed by the doctor.
DATA ENTRY EDITS N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 20 DESCRI PTI ON: DATE D/C SUMMARY TYPED TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date the discharge summary was typed.
FIELD NAME: DCTYPED
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Dated Typed:
HELP TEXT: Enter the numeric equivalent of the month, day and year of the dat e the discharge summary was typed.
DATA ENTRY EDITS N/A
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is suggested for inclusion in all patient records.
REASON FOR COLLECTI NG: Data quality tracking, CQI
Page 21 DESCRI PTI ON: DATE LEGAL STATUS EXPIRES TOC Index
DEFI NITION: The numeric equivalent of the month, day and year of expiration of the current legal stat us of the client.
FIELD NAME: STATEXP_DT (STATEXP_)
FORMAT: MMDDYYYY Length = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991)
DATA ENTRY PROMPT: N/A
HELP TEXT: The date of expiration of the client's current l egal stat us is automatical ly calculated and displayed when the user enters the date and ti me of the execut ion of the cli ent' s current legal status.
DATA ENTRY EDITS: N/A
MISSING DATA LOGIC: N/A
INDICATORS: N/A
REASON FOR COLLECTI NG: Legal tracki ng
Page 22 DESCRI PTI ON: DATE OF ADMISSION TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the date of the client's formal admission (current episode) to the hospital/acute unit.
FIELD NAME: ADM_DATE
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=Day (01-31) YYYY=Year (e.g. , 1991) A valid date must be entered (e.g., 02/30/1993 is not a valid date).
DATA ENTRY PROMPT: Admit Date: / /
HELP TEXT: Enter the numeric equivalent of the month, day, and year of the date the client was admitted to the facility as an inpatient. MANDATORY FIELD: This field may not be left blank at admissi on.
DATA ENTRY EDITS: 1. The Admission Date cannot be blank. 2. The Admissi on Date must be the same as or prior to today's date. 3. The Admissi on Date cannot be earlier than the Date of Pre-Admission Interview. 4. The Admission Dat e must be withi n 31 days of t he Date of Pre-Admission Interview. 5. The Admissi on Date cannot be earl ier than t he discharge date for the pr evious episode of care. 5. The Admission Date cannot be later than the discharge date for that stay.
MISSING DATA LOGIC: This data is considered missing if t his field is left blank.
INDICATORS: This data element is required for all client records.
REASON FOR COLLECTI NG: MHSIP
Page 23 DESCRI PTI ON: DATE OF BIRTH TOC Index
DEFI NITION: The numeric equivalent of the month, day, and year of the client's date of birth.
FIELD NAME: BIRTHDATE (BIRTHDAT)
FORMAT: MMDDYYYY Lengt h = 8 Type = Date Popup used = N/A
ALLOWABLE VALUES: MM=Month (01-12) DD=