Department of Human Services (DHS)Division of Mental Health and Addiction Services (DMHAS)Office of theResearch, Planning, Evaluation, Information Systems and Technology
Data Entry form on PaperFor the
NEW NJSAMS DischargeModule
(Please download and keep extra copies at all time in case of Internet Connection failure and System unavailable)
NJSAMS Real-time Data System (Do not use training or demo. purposes)
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Phone: 609-777-2164
Updated 07/28/2014
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Page 1 of 9
CLIENT DISCHARGE FORM IN NJSAMS
NJSAMS Data Entry Form for Admission Page 1 of 9 DMHAS – Prepared by Kyu Kyu Hlaing
Personal Information
Personal Information(populated info – not editable.)
Client’s:
______
First name Middle name Last name
Date of Birth: ______Gender: ______
Admission Details(populated info – not editable)
Date of Admission: ______
Level of Care: ______
Discharge Details / Education / Employment / Drug Use / Legal Information / Goal Achievement / Reason
Discharge Details
Discharge Date: ______
Counselor Name: ______
Living Arrangement
Living Arrangement at Discharge: Dependent Living/Institution
Homeless – Shelter
Homeless – Street
Independent Living
Education / Employment
Is client currently enrolled in school or a job training program?
- Not enrolled
- Enrolled Full Time
- Enrolled Part Time
- Other
Which best describes the client's CURRENT Employment situation?
-Full-time work or military (35 hours a week or more)
-Part-time (less than 45 hours a week)
-Student
-Home Maker
-Retired
-Unemployed: Actively looking for work
-Unemployed: Not looking for work
-Unemployed: Volunteer Work
-Unemployed: Living in an institution
-Disabled
Drug Use
Is Client using drugs or alcohol at Discharge?
Primary Drug
-Yes, Alcohol;
-Yes, Drugs;
- No Alcohol & No Drugs;
- Unknown
-Drug Name:
-AlcoholAlprazolam (Xanax)
-Amphetamine Barbituates
-Benzodiazepine
-Buprenorphine (non-prescription)
-Chlordiazepoxide (Librium)
-Clorazepate (Tranxene)
-Cocaine - Powder
-Codeine
-Crack
-Diazepam (Valium)
-Flurazepam (Dalmane)
-GHB
-Hallucinogens - LSD
-Hallucinogens - PCP
-Heroin
-Hydrocodone (Vicodin)
-Hydromorphone (Dilaudid)
-Inhalants
-Ketamine, Special K
-Lorazepam (Ativan)
-Marijuana/Hashish
-MDMA (MOLLY), Ecstasy
-Meperidine (Demerol)
-Methadone (non-prescription)
-Methamphetamines
-Methylphenidate (Ritalin)
-Opiate - Other
-Oxycodone (Oxycontin)
-Pentazocine (Talwin)
-Propoxyphene (Darvon)
-Rohypnol (Roche, Rope, Roach)
-Synthetic cannabinoids (Synthetic Marijuana, K2, Spice, Bath Salts)
-Tramadol (Ultram)
-Other
-
Route of Administration (Primary Drug):
- Oral
- Inhalation/Sniffing
- Smoking
- Intramuscular/sub-cutaneous
- Intravenous
Frequency of Use (Primary Drug):
- No use past month
- Less than weekly
- 1 to 2 times per week
- 3 to 6 times per week
- Daily
- N/A
Age at first use for Primary: ______years-old
Secondary Drug
Drug Name:
-AlcoholAlprazolam (Xanax)
-Amphetamine Barbituates
-Benzodiazepine
-Buprenorphine (non-prescription)
-Chlordiazepoxide (Librium)
-Clorazepate (Tranxene)
-Cocaine - Powder
-Codeine
-Crack
-Diazepam (Valium)
-Flurazepam (Dalmane)
-GHB
-Hallucinogens - LSD
-Hallucinogens - PCP
-Heroin
-Hydrocodone (Vicodin)
-Hydromorphone (Dilaudid)
-Inhalants
-Ketamine, Special K
-Lorazepam (Ativan)
-Marijuana/Hashish
-MDMA (MOLLY), Ecstasy
-Meperidine (Demerol)
-Methadone (non-prescription)
-Methamphetamines
-Methylphenidate (Ritalin)
-Opiate - Other
-Oxycodone (Oxycontin)
-Pentazocine (Talwin)
-Propoxyphene (Darvon)
-Rohypnol (Roche, Rope, Roach)
-Synthetic cannabinoids (Synthetic Marijuana, K2, Spice, Bath Salts)
-Tramadol (Ultram)
-Other
Route of Administration (Secondary Drug):
- Oral
- Inhalation/Sniffing
- Smoking
- Intramuscular/sub-cutaneous
- Intravenous
Frequency of Use (Secondary Drug):
- No use past month
- Less than weekly
- 1 to 2 times per week
- 3 to 6 times per week
- Daily
- N/A
Age at first use for Secondary: ______years-old
Tertiary Drug
Drug Name:
-AlcoholAlprazolam (Xanax)
-Amphetamine Barbituates
-Benzodiazepine
-Buprenorphine (non-prescription)
-Chlordiazepoxide (Librium)
-Clorazepate (Tranxene)
-Cocaine - Powder
-Codeine
-Crack
-Diazepam (Valium)
-Flurazepam (Dalmane)
-GHB
-Hallucinogens - LSD
-Hallucinogens - PCP
-Heroin
-Hydrocodone (Vicodin)
-Hydromorphone (Dilaudid)
-Inhalants
-Ketamine, Special K
-Lorazepam (Ativan)
-Marijuana/Hashish
-MDMA (MOLLY), Ecstasy
-Meperidine (Demerol)
-Methadone (non-prescription)
-Methamphetamines
-Methylphenidate (Ritalin)
-Opiate - Other
-Oxycodone (Oxycontin)
-Pentazocine (Talwin)
-Propoxyphene (Darvon)
-Rohypnol (Roche, Rope, Roach)
-Synthetic cannabinoids (Synthetic Marijuana, K2, Spice, Bath Salts)
-Tramadol (Ultram)
-Other
Route of Administration (Tertiary Drug):
- Oral
- Inhalation/Sniffing
- Smoking
- Intramuscular/sub-cutaneous
- Intravenous
Frequency of Use (Tertiary Drug):
1.No use past month
2.Less than weekly
3.1 to 2 times per week
4.3 to 6 times per week
5.Daily
6.N/A
Age at first use for Tertiary: ______years-old
Legal Information
What is client's current Legal Status? (Check all that apply)
- No Legal Problem
-
Case Pending
-
Drug Court
-
Probation
-
Parole
-
DWI License Suspension
-
Jail/Prison Inmate
-
CWP (CP and P) or Family Court
-
Other; if Other Specify: ______
How many times has client been arrested and charged for an offense in the past 30 days? How many times has client been arrested and charged for an offense in the past 30 days?
______Time(s) (If none, enter 0)
Evaluation of Client Goal Achievement
Alcohol/Drug Problem: Achieved
Partially Achieved
Not Achieved
Not Applicable
Educational: Achieved
Partially Achieved
Not Achieved
Not Applicable
Employment/Vocational: Achieved
Partially Achieved
Not Achieved
Not Applicable
Legal: Achieved
Partially Achieved
Not Achieved
Not Applicable
Family Situation/Social: Achieved
Partially Achieved
Not Achieved
Not Applicable
Psychological/Mental Health: Achieved
Partially Achieved
Not Achieved
Not Applicable
Physical Health : Achieved
Partially Achieved
Not Achieved
Not Applicable
Discharge Reason
Date of last face to face Client contact: ______
Discharge Reason
Reason for Discharge: Treatment plan completed at this level of care
Treatment plan not completed
Discharged to DCF-CSOC
If treatment not completed:
-Quit or dropped out
-Needs different Level Of Care
-Unable to meet client’s non-substance abuse treatment needs
-Administrative Discharge / Rule Non-compliance
-Exhaustion of insurance benefits or ability to pay
-Loss of eligibility for Medicaid or Medicare
-Incarcerated – status revocation
-Incarcerated – charge since entering treatment
-Incarcerated – charge since entering treatment
-Medical discharge / Hospitalized
-Deceased
-Refused continuing care
-Treatment needed unable to continue
-Other
Continuing Care Type
-No continuing substance abuse treatment needed
-Refused continuing care
-Treatment needed unable to continue
-Transfer to different level of care within same agency and clinic
site
-Transfer to a new clinic site location within same agency
-Continuing care coordinated with new agency
Continuing care NJSAMS treatment agency: (if transfer to another agency)
Self-Help / Recovery Support
Self-Help
In the past 30 days, did client attend any Self-Help Groups? (Check all that apply)
-Narcotics Anonymous (NA)
-Alcoholics Anonymous (AA)
-Any religious or faith affiliated recovery Self-Help Group
-Other Self-Help/Mutual Support Groups
Frequency of Attendance:
-No Attendance in the past month
-1-3 times in the past month (less than once per week)
-4-7 times in the past month (about once per week)
-8-15 times in the past month (2 to 3 times per week)
-16-30 times in the past month (4 or more times per week)
-Some attendance but frequency unknown in the past month
-Unknown
Recovery Support
In the past 30 days, did client have interaction with family and/or friends that are supportive of his/her recovery?
Yes No Refused to answer Don’t know
To whom, does the client turn to when he/she is having trouble that is supportive of his/her recovery?
No One Counselor Clergy Family Member
Friends Other ______
Refused to answer Don’t Know
Significant Problems(Check all that apply)
Significant problems and conditions present at admission or identified
during treatment
-Not Applicable
-Batterer
-Child of Substance Abuser
-Compulsive Gambling
-Criminal Activity
-Mental Health problem
-Neglect/Abuse of Client’s Children
-Physical Disability/Handicap
-Pregnancy
-Runaway Behavior
-Suicide Attempt
-Victim of Physical Abuse/Neglect
-Victim of Sexual Abuse
-Other; if Other specify: ______
Referrals
Substance Abuse Services
-Employee/Student Assist. Program
-Alcoholics Anonymous
-Narcotics Anonymous
-Family-Oriented Self-Help Program
-Other Self-Help Program; if Other Specify: ______
Supportive Services
None
Clergy
Educational
Employment
Family Services
Food stamp/Food
Gambling
HIV/AIDS Testing
Housing
Legal
Medical
Mental Health
Public welfare
Pre-Natal
Social Services
TB Services
Tobacco
Vocational Rehab
Women’s Center
Other if Other Specify: ______
Medication / Services by Agency
Unit of Service
Units of service for client (Non-Residential):
______days/sessions
Units of service for co-dependents not reportedseparately:
______days/sessions
Medication
Medication prescribed to treat substance abuse (check all that apply)
-Methadone
-Buprenorphine
-Acamprosate
-Naltrexone (oral)
-Vivitrol
-Psychotropic Medication
-Other if other Specify: ______
-No
-Don’t Know
Supportive Services
Services provided by agency during treatment(check all that apply)
-Anger Management/Resolution Interventions
-Case Mgmt: DYFS or Other Child Protective Service
-Case Mgmt: Judge or Court
-Case Mgmt: Parole or Probation
-Case Mgmt: Public Assistance (TANF, WIC, Food Stamps etc)
-Case Mgmt: Other
-Counseling – Family
-Counseling – Group
-Counseling – Indivisual
-Education Service
-Housing Assistance
-Job/Vocational Assessment, Training
-Legal Assistance or Services
-Medical Testing or Services
-Mental Health Testing or Services
-Parenting/ Family Interventions
-Personal Needs: Food, Clothing
-Rape/ Sexual Abuse Interventions
-Self-Help: Alcoholics Anonymous
-Self-Help: Narcotics/Cocaine Anonymous and other
-HIV/AIDS Testing
-TB Services
-Other
Mantoux Tuberculin Skin Test / Hepatitis Test /
HIV / Toxicology Test
Mantoux Tuberculin Test
Was any Mantoux Tuberculin Skin Test during treatment?
-Positive at this Facility
-Positive at Other Facility
-Negative
-Refused
-Not Offered
-Mantoux TST Given, Not Read
-Other
-Unknown
If positive: Date: ______
Tuberculin Treatment Started? Yes No
Hepatitis Test
Was Client Tested for Hepatitis during treatment?
-Positive at this Facility
-Positive at Other Facility
-Negative
-Refused
-Not Offered
-Hepatitis Test Done, Not Read
-Other
-Unknown
If positive: Date: ______Positive at Hepatitis: A B C D E
Hepatitis Treatment Started? Yes No
HIV Test
-Tested
-Offered but refused
-Not offered
-Unknown
If Tested: If tested: Did client get HIV test result?
-Yes
-Client Refused Result
-Client Discharged before results Given
-Unknown/Don’t Know
Toxicology Test
Was Urine analyzed for illegal drug?
Yes No Don’t Know
If Yes: How many tests were done? ______
How many tests were positive for drugs? ______
______
NJSAMS Data Entry Form for Admission Page 1 of 9 DMHAS – Prepared by Kyu Kyu Hlaing
Discharge Comment (it can be discharge report, recommendations and findings)
NJSAMS Data Entry Forms Page18 of 18 Any questions please call (609) 292-1466, (609) 943-5905