Resident/Client Discharge Data Entry Form
Important Confidentiality Information:
All persons filling out and (or) entering this information into CMHC must sign and adhere to
the YCS Confidentiality agreement. If you have not done so, contact the HR dept. for a confidentiality agreement. Sign and return the agreement as soon as possible to HR.
CMHC – Client Discharge
Signature of Site Administrator:
Sign off indicates agreement of completion. ______
(All applicable fields filled in & entered into CMHC.)
Last Name: ______
First Name: ______
Date of Birth: ___/___/___
Discharge Information - To be completed whenever a client is Discharged from your program.
In Client Registration select the Discharges button along the bottom in your client’s record.
Click on the New button at the top. This will open a new discharge screen in the discharge
EDIT Tab.
Discharge date: ___/___/___
Type: (Client discharged to – choices include everything listed up until the ‘Program’ Field)
Circle one:
Emergency / Inpatient
C = CCIS / Psychiatric inpatient
G = General Hospital
Community Programs / Residential Sources Legal/Justice System
H = Community mental health agency S = Police / Court/ Jail
J = Alcohol treatment program T = State correctional pgm
K = Drug treatment program V = Community corrections pgm
L = School District/Child study team W = Family crisis intervention unit
M = Other social service agency
N = Nursing home
O = Boarding home
P = Homeless shelter
R = RTC [Residential Treatment Center]
Y = Treatment Home / Foster Home
Z = Group Home
Individuals Dept. of Human Services – [DHS]
X = Self / Independent living 6 = DYFS
1 = Family 7 = Div. of Developmental Disability
10 = Adopted *8 = Other [DHS service]
11 = Friend * When using “Other” always include a brief
explanation below to be entered into the Desc
(description) field under Type of Discharge :
______
______
______
______
9 = AWOL [Do Not use selection 9 or Q in USTF]
* Q = Other [non DHS]
* When using “Other” always include a brief explanation below to be entered into the Desc
(description) field under Type of Discharge :
______
______
______
______
Program : (Your 3 digit code, same as department code) ____
Staff : (Staff member involved in the client discharge) ____
[F2 Key in field for selection list]
Now Click on the User Tab (still in discharge)
Tab to the Notes1 section and type in the following information.
** Indicate in the Notes1 section - who the person is – i.e.: (Parent) should follow name
Parent or Guardian’s Name: ______
Street Address: ______
City or town: ______
State: ____ Zip:______
County: ______
Residence client is transitioned to:
Contact person’s last name: ______
[*From the program the child is going to – if known]
Contact person’s first name & middle initial: ______
Contact person’s address (If not the same as the above)
Street Address: ______
City or town: ______
State:____ Zip: ______
County: ______
______
Circ.Dis (Circumstances at discharge, circle one) :
A=Termination with referral attempted G=Client lost to contact, no follow-up
B=No further services needed H=Client moved/ Known to be unavailable
L=Addt’l services needed and have been arranged I=Client died on the premises
C=Addt’l services needed but not available J=Client died off the premises
D=Addt’l services needed but rejected by client (Includes AWOL) K=Transfer within YCS ** See note below
E=Addt’l services needed but rejected by parent / guardian F=Client lost to contact, follow-up attempted, no contact made
**Note:Transfer should Only be used if
a client has been in your program less than 90 days and is transferred to
another YCS program.
Trtmnt Out (Treatment outcome, circle one) :
A=Treatment goals met – Appropriate Discharge E=Treatment goals not met –
B=Treatment goals met – Inappropriate Discharge Appropriate Discharge
C=Some treatment goals met – Appropriate Discharge F=Treatment goals not met –
D=Some treatment goals met – Inappropriate Discharge Inappropriate Discharge
G=Transfer within YCS ** See not above
(User Tab continued)
Ed Goals (Education Goals outcome, circle one) :
A=Education goals met – Appropriate Discharge G=Continued Education/Entered Vocational/
B= Education goals met – Inappropriate Discharge Trade School
C=Some Education goals met – Appropriate Discharge H=Continued Education/College
D=Some Education goals met – Inappropriate Discharge I=Military Enlistment
E= Education goals not met – Appropriate Discharge J=Secured Employment
F= Education goals not met – Inappropriate Discharge K=Transfer within YCS **
(see prior page Note** for explanation)
# Hospitalizations in Pgm: _____
(Number of psychiatric hospitalizations client had while in your program.
*If there were No psychiatric hospitalizations while in your program enter a 0. )
Final GAF: (last GAF score - for discharge) ______
If your program does not do client testing enter a 1 here.
Living Circ: (What the living circumstance after discharge will be, circle one)
A = Alone / Independent
B = With relatives / Family / Friend
Q = Newly Adopted Family
C = Foster Care
D = RTC [Residential Treatment Center]
F = Shelter
G = Group Home
H = Hospital
K = Incarcerated
L = IRTS [Intensive Residential Treatment Service]
M = PCH / PCR [Psychiatric Children’s Home / Residence]
N = Specialty Beds [SPEC]
P = Treatment Home
J = Unknown
E = Other
(When you are in USTF only A, B or C can be used)
PermOut (Permanency Outcome for all Residential programs, circle one) :
A = Reunified: Planned discharge: Returned to biological or adoptive family
B = Stabilized: Planned discharge: Remained in the community with biological or adoptive family or
discharge to community placement [long term foster care/treatment home,
independent living, graduate program]
C = Other: Transfer, Residential program/ Group Home, AWOL, jail, hospital, or other type of specialized
treatment facility
[Save your Discharge now.]
Admissions / Terminations screen
After Saving you will be automatically brought to Admissions / Terminations screen.
Enter the termination date on the same line with the admit date. The termination date will be the same
as the discharge date.
If for any reason you are not brought here automatically, click on the Programs button and
then enter the termination date on the same line with the admit date.
This date is required for client to be discharged in system.
January 2012
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