Last Name: / Place Holder / First Name: / Place Holder / Unique Identifier: / Free text
Clinician: / Dropdown list (editable) / DOB: / Place Holder / Age: / Place Holder
Address: / Free text / Sex: / Place Holder / Phone number / Free Text / Lang: / (Drop Down, e-Center get state list)
Living Situation: / (Drop Down:
e-Center get list from Karin) / Date Started in Living Situation: / Click here to enter a date. / Ethnicity: / Place Holder
Originating Agency / Free Text / First Contact Date: / Click here to enter a date. / Emergency Contact / Free Text / Free Text
Screening and Other Frequent Data / Diagnoses
Type / Date Taken / Agency / Value / Type / Check as appropriate / Source of Info
BP (Diastolic) / Click here to enter a date. / Dropdown list (editable) / Enforced range / Medical / o DM
o HTN
o Dyslipidemia / Free text
BP (Systolic) / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
Weight / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
Height / Click here to enter a date. / Dropdown list (editable) / Enforced range / Psychiatric / o Bipolar
o Schizophrenia
o Depression
o Anxiety
o PTSD
o Psychosis / Free text
BMI / Click here to enter a date. / Dropdown list (editable) / Calculated / Free text
PHQ-2 / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
PHQ-9 / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
SIA / Click here to enter a date. / Dropdown list (editable) / Need Dropdown List / Free text
SID / Click here to enter a date. / Dropdown list (editable) / Need Dropdown List / Free text
GAD-2 / Click here to enter a date. / Dropdown list (editable) / Need Dropdown List / Substance Use Disorder / o Alcohol Use
o Opiate Use
o Stimulant Use
o Tobacco Use
o Sedative Use
o Others / Free text
A1c / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
LDL / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
Experience of Care / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
Confidence / Click here to enter a date. / Dropdown list (editable) / Enforced range / Free text
Coordination / Click here to enter a date. / Dropdown list (editable) / Enforced range / Other / Free text / Free text
Care Coordination Team
Type / Name / Agency Name / Phone / Email / Unique Identifier / ROI Date
Care Coordinator / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
Clinical Care Manager / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
Primary Care / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
Mental Health / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
Substance Use / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
Peer and/or Family Member Provider / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
Health Plan / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
Other 2 / Dropdown list (editable) / Dynamic based on name / Dynamic based on name / Dynamic based on name / Free text / Calendar Select
REFERRAL(S) STATUS
Agency Referred to: / Contact Name: / Phone number / Date of Referral / Current Status / Completed Date / Summary Report Received Date
1. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
2. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
3. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
4. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
5. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
6. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
7. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
8. Dropdown list (editable) / List dynamic based on Organization / Dynamic based on Contact Name / Click here to enter a date. / Choose an item. / Click here to enter a date. / Click here to enter a date.
Planning and Care / Date / Shared Care Objectives (insert text box approximately one inch high. Prepopulate with numbers 1, 2, and 3. Limit characters- 512) / Notes
Shared Medication Reconciliation / Click here to enter a date.
Treatment/Shared Care Objectives / Click here to enter a date.
Most Recent ER Visit / Click here to enter a date.
Most Recent
Hospitalization / Click here to enter a date.
Organization / Date Updated / List of Medications
Medication from Primary Care / Date picker / Text entry
Medication from Mental Health
Medication from Substance Use
Health Plan
Descriptions of Tracking Data Elements
Clarifications Needed:
-how to set this up when the data item needs to be entered each visit (regardless of whether the new value is the same or different than the previous)
-What about edits? How does editing previously entered data affect the date stamp? (Including if the “Visit Date” is edited…which should affect all of the other date stamps for the items changed during that visit.) Can a visit be deleted? If so, how does this affect the connection between visits?
Item / Description / No. of Characters / Data Entry / Date Stamped? / Special Instructions /Name of Person / Person entering data / 25 / Auto fill from logon / Date entered
Name of Org / Organization for which the person entering the data works / 25 / Auto fill from logon / Date entered
Visit Date / Date of visit / 8 / Month/Day/Year (00/00/00) / Date entered
Date Entered / The date the data is entered into the system / 8 / Auto fill from logon
Month/Day/Year (00/00/00) / Date entered
CLIENT INFORMATION
Last Name: / ? / Free text; default is “Unknown” / Visit Date when entered or changed / Previously entered name is not lost
First Name: / ? / Free text; default is “Unknown” / Visit Date when entered or changed / Previously entered name is not lost
Unique Identifier: / Medical Record Number, SSN, or ?? The unique identifier agreed upon by care coordination team / 16 / Free text; default is “Unknown” / Visit Date when entered or changed / Previously entered Unique Identifier is not lost
Clinician: / Person who does the service providing for the organization entering the current data (could be same as “Name of Person above) / 25 / Dropdown list (editable)
DOB: / Date of Birth / 8 / Month/Day/Year (00/00/00) / No / Previously entered DOB is not lost
Age: / 3 / Calculated / No / Calculated - automatic
Address: / Best known physical address for client / 45 / Free text / Visit Date when entered or changed / Previously entered address is not lost
Sex: / M, F, Other / 12 / Dropdown list (NOT editable) / Previously entered Sex is not lost
Phone Number: / Phone number / 14 / Enter the number and system automatically formats / Previously entered phone number is not lost
Language: / Preferred language of the client / 25 / Dropdown list (editable) / Previously entered language is not lost
Living Situation: / (Drop Down:
e-Center get list from Karin) / 25 / Dropdown list (editable) / Previously entered housing type(s) is not lost
Date Started in Living Situation: / The date the data is entered into the system / 8 / Month/Day/Year (00/00/00) / Visit Date when entered or changed / Previously entered date is not lost
Ethnicity / 21 / Pull-down list of ethnicities (which includes “other”) / Visit Date when entered or changed / Previously entered ethnicity is not lost
Originating Organization: / This is the organization who had first contact with the client / 25 / Dropdown list (editable) / Previously entered organization is not lost
First Contact Date: / This is the date of the first contact by the Originating Organization / 8 / Month/Day/Year (00/00/00) / Visit Date when entered or changed / Previously entered date is not lost
Emergency Contact:
(Name) / Client’s preferred emergency contact / 25 / Free text / Previously entered contact name is not lost
Emergency Contact:
(Contact Info) / Contact information for client’s preferred emergency contact / 25 / Free text / Previously entered contact info is not lost
Screening and Other Frequent Data
Each screening or data element in this section has a “Date Taken” which will be entered from a calendar with default date of today, an Organization name of where the value was taken or gathered from the client (dropdown editable list), and the values described below
BP (Diastolic): / Diastolic blood pressure / 3 / Whole numbers between 50 and 130 / Visit Date when entered or changed / Previously entered value is not lost
BP (Systolic): / Systolic blood pressure / 3 / Whole numbers between 70 and 220 / Visit Date when entered or changed / Previously entered value is not lost
Weight: / Weight of the client / 3 / Number between 70 and 600 / Visit Date when entered or changed / Previously entered value is not lost
Height: / Height of the client / 6 / Should be formatted as:
X’ YY” / Visit Date when entered or changed / Previously entered value is not lost
BMI: / Body Mass Index / 4 / Automatically calculated from height and weight (format XX.X) / Visit Date when entered or changed / Auto-calculated
PHQ-9: / Score from Patient Health Questionnaire survey / 2 / Whole number between 0 and 27 (inclusive) / Visit Date when entered or changed / Previously entered value is not lost
CAGE: / Hours worked in the last week / 1 / Whole number between 0 and 4 (inclusive) / Visit Date when entered or changed / Previously entered value is not lost
Other Screen: Dropdown list (editable) / The name of the screening tool will need to be in the first cell, chosen from an editable dropdown list. / ? / Could be text as well as numeric???? / Visit Date when entered or changed / Previously entered name of screening tool, date, org name, and value are not lost
Other Screen: Dropdown list (editable) / The name of the screening tool will need to be in the first cell, chosen from an editable dropdown list. / ? / Could be text as well as numeric???? / Visit Date when entered or changed / Previously entered name of screening tool, date, org name, and value are not lost
Other Screen: Dropdown list (editable) / The name of the screening tool will need to be in the first cell, chosen from an editable dropdown list. / ? / Could be text as well as numeric???? / Visit Date when entered or changed / Previously entered name of screening tool, date, org name, and value are not lost
A1c: / Glycated hemoglobin / 4 / Normally measured to a tenth
Minimum 3, maximum 30 / Visit Date when entered or changed / Previously entered value is not lost
LDL: / low-density lipoprotein / 3 / Normally measured in whole numbers
Minimum 30, maximum 300 / Visit Date when entered or changed / Previously entered value is not lost
Experience of Care: / One of four questions given to clients at each visit / 1 / 1 to 5 (Whole numbers) / Visit Date when entered or changed / Previously entered value not visible
Wellness: / One of four questions given to clients at each visit / 1 / 1 to 5 (Whole numbers) / Visit Date when entered or changed / Previously entered value not visible
Confidence: / One of four questions given to clients at each visit / 1 / 1 to 5 (Whole numbers) / Visit Date when entered or changed / Previously entered value not visible
Coordination: / One of four questions given to clients at each visit / 1 / 1 to 5 (Whole numbers) / Visit Date when entered or changed / Previously entered value not visible
DIAGNOSES
This section has a list of diagnoses (15 with check boxes and an addition free form one). For each of the 15, data entry is done by clicking on the checkbox to indicate a “Yes”, then the data entry person can optionally add a text description of the source of the diagnosis information. The one (last) Other diagnosis has a place to type in a free text name of a diagnosis and the source. All of these fields (checkboxes and free text) have memory of previous entries.