TABLE OF CONTENTS - HL7.org

TABLE OF CONTENTS



WHO TO CALL 4

CLIENT DATA CORE 5

CONTACTS 7

ADMISSION 9

SECTION I 10

SECTION II 16

SECTION III 23

SECTION IV 28

SECTION V 29

LEVEL OF CARE CHANGE 36

DISCHARGE 38

DISCHARGE/COMPLETED TREATMENT 39

DISCHARGE/COMPLETED COURT COMMITMENT 40

DISCHARGE/LEFT AGAINST COUNSELOR'S ADVICE (ACA) 41

DISCHARGE/MOVED 42

DISCHARGE/TRANSFERRED TO ANOTHER TREATMENT FACILITY 43

DISCHARGE/INCARCERATED 44

DISCHARGE/BROKE RULES 45

DISCHARGE/ABSENT WITHOUT LEAVE (AWOL) 46

DISCHARGE/DEATH 47

DISCHARGE/FAILED TO BEGIN TREATMENT 48

DISCHARGE/DUE TO TREATMENT INCOMPATIBILITY 49

DATA UPDATES 50

SERVICES SHEET 51

HOURLY SERVICES/ACTIVITY REPORTING 52

DAY SERVICES REPORTING 56

SECTION VI 60

CODE LISTS 60

CONTRACT SOURCES 60

DEFINITION OF SERIOUS MENTAL ILLNESS (SMI) 62

DEFINITION OF SERIOUS EMOTIONAL DISTURBANCE (SED) 64

DRUGS OF CHOICE 66

USUAL ROUTE OF ADMINISTRATION 66

FREQUENCY OF USE 66

HANDICAP INDICATORS 69

LEGAL STATUS 70

MILITARY TIME CHART 72

OKLAHOMA COUNTIES 73

PRESENTING PROBLEMS 75

REFERRALS 78

LEVELS OF CARE AND SERVICES 79

LIST OF SERVICE CODES 110

NUMERICAL LISTING OF DSM-IV DIAGNOSES AND CODES 113

ALPHABETICAL LISTING OF AGENCIES 120

STAFF PROFILE 121

DMHSAS STAFF PROFILE CODES 125

AGENCY FORM 126

INDEX 125

1 INTRODUCTION



The Oklahoma Integrated Client Information System (ICIS) is a
comprehensive management information system based on national
standards for mental health and substance abuse databases. It is a
repository of diverse data elements that provide information about
organizational concepts, staffing patterns, client profiles, program
or treatment focus, and many other topics of interest to clinicians,
administrators and consumers. It includes unique identifiers for
agencies, staff, and clients that provide the ability to monitor the
course of client services throughout the statewide DMHSAS network.
ICIS collects data from hospitals, community mental health centers,
substance abuse agencies, domestic violence service providers,
residential care facilities, prevention programs, and centers for the
homeless which are operated or funded in part by DMHSAS.


The information obtained through ICIS is utilized in many ways.
Reports are produced to monitor contractual requirements. Reports
requested by the state legislature or mandated by federal funding
regulatory agencies are also compiled as needed.


The Oklahoma Mental Health Information System (OMHIS) was conceived in
1978 as primarily a statistic-gathering mechanism. Since then, it has
grown and undergone revisions to keep abreast of federal and state
mandates; to meet the specific information needs of DMHSAS-supported
treatment programs and planning efforts around the state and to
address administrative and legislative information requirements.


Until July 1, 1997, all agencies were required to report all services
provided, regardless of pay source, to DMHSAS. The reporting policy
currently states that agencies are now only required to report
services paid by DMHSAS, either in part or fully. This includes
services billed to Medicaid. Beginning July 1, 1999, ICIS also began
gathering information from which agencies are paid.





2 ICIS


2 WHO TO CALL



For questions about ICIS reporting procedures and training, call Shalonna
Daniels, the ICIS Coordinator at (405) 522-3820.


For questions about ICIS online entry such as acquiring a login ID and
password and how to access/enter data, call Donald DeVault, Information
Services Support Specialist, at (405) 522-3964.


Questions about contract issues should be addressed to staff in the
contracts unit. For substance abuse or prevention contracts please call
Bryan Wiewel, (405) 522-3864. For mental health, domestic violence,
residential care home or other contract questions please call Linda
Lechtenberg, (405) 522-3852. For general contractual questions you may
call (405) 522-5105.




CLIENT DATA CORE



T
he Client Data Core (CDC) is a multi-purpose form. This form records
contact interviews, admissions, changes in treatment, level of care, and
discharges. The CDC collects socio-demographic information about the client
in addition to diagnostic information. The CDC is the initial form that
establishes the client data file on an individual and is the first
introduction of the Client Identification Number (Client ID) to the system.
The CDC data is utilized for a multitude of purposes, e.g., linkage of
services throughout facilities statewide, eligibility determination,
identification of target groups being served, recording history of drug
abuse, or identifying persons with serious mental illness being served.
All information reported on the CDC must refer to the individual for whom
services are being sought, even when a family member, spouse, or other
person precipitates the contact or admission.




CONTACT TRANSACTIONS SIGNIFY THAT AN ADMISSION WAS NOT APPROPRIATE
OR WAS UNATTAINABLE FOR THIS INDIVIDUAL AT THE TIME OF CONTACT.
SERVICES PROVIDED MUST BE ON THE SAME DATE AS THE CONTACT.




Examples might include: (1) an individual who was seen by a staff member,
but an admission to the agency did not occur due to an emergency situation;
(2) the client was ambivalent regarding the initiation of treatment
services; (3) a referral to a different facility for treatment was deemed
appropriate; or (4) the client refused treatment.



ADMISSION TRANSACTIONS REFLECT THE BEGINNING OF A TREATMENT
REGIMEN FOR THE CLIENT.




Admission information includes who referred the client for services;
treatment program type or Level of care to which the client is admitted;
and social and financial information regarding the client. An admitted
client may also be referred to as an active client. A client (i.e., a
client's records) will remain active until a discharge transaction is
reported.




A LEVEL OF CARE TRANSACTION REFLECTS A SIGNIFICANT CHANGE IN THE
TREATMENT ACTIVITIES A CLIENT WILL BE RECEIVING.




For example, a client admitted to a residential program may be transferred
to a halfway house program sponsored by the same agency. In this case, the
client would have a level of care change from Intensive Residential
Treatment (CI) to Community Living (CL). Clients receiving services from
the agency, regardless of the service activities, are always considered
active clients. When a client has a change in a program environment, within
the same agency, a Level of care change is always reported. Level of care
changes allows the CDC to track changes in program focus, intensity of
care, and service provision within the same organizational structure. A
discharge transaction is not valid when continuing services are being
provided by the agency, regardless of location or service intensity.




DISCHARGE TRANSACTIONS SIGNIFY THAT ALL SERVICES FOR THE CLIENT
HAVE BEEN TERMINATED.




Once a client is discharged, any future encounter with the individual will
necessitate reporting an admission, or, if appropriate, a contact
transaction.


The CDC is also utilized to report an information update transaction.




AN INFORMATION UPDATE TRANSACTION IS REQUIRED WHEN SIGNIFICANT
EVENTS OCCUR THAT NEED TO BE REFLECTED IN THE CLIENT'S FILE.




For example, this might be a change in a diagnosis, legal status, or a
change in income.

1 CONTACTS



A


contact is an encounter with an individual that does not necessitate an
admission. Contacts are never reported in the place of an admission.
Once an agreement to render and to receive services has been reached, an
admission is processed.


CONTACTS ARE AVAILABLE FOR THOSE INSTANCES WHEN AN ADMISSION IS
NOT APPROPRIATE OR ATTAINABLE, E.G., REFERRALS OR EMERGENCY
INTERVENTIONS. THE INTENT OF THE CONTACT TRANSACTION IS TO REPORT
THOSE OCCURRENCES IN WHICH STAFF SPEND TIME WITH AN INDIVIDUAL FOR
WHOM AN ADMISSION IS DEEMED INAPPROPRIATE OR UNATTAINABLE.




There is no system limitation on the number of non-emergency contacts
(21) that can be reported.




CONTACT 21 AND FAMILY SUPPORT CONTACT TRANSACTIONS REQUIRE THE
COMPLETION OF SECTION I OF THE CLIENT DATA CORE (CDC). TO ENTER A
CONTACT ONLINE, GO TO THE CONTACTS LINK ON THE HOME PAGE.


If enough information can be gathered about a contact (21), complete
Section I of the CDC and report the service with the unique Client ID.
If not enough information is known, a crisis service can be reported
to an unknown client using the EC client ID. See Section 5 for more
information.


Family Support Contacts may be used by agencies providing services to
family members of substance abuse clients. The contact only needs to
be reported once, and the family support service, service code 224,
may be reported as long as necessary. As part of this contact,
complete the Family Identifier field (a