Free HSRS AODA Module Deskcard - Wisconsin

2009 HSRS AODA MODULE DESKCARD
MODULE TYPE 6
CLIENT CHARACTERISTICS (Field 8)
19 23 25 26 27 28 29 86 02 03 14 04 05 10 12 16 17 39 07 08 32 79 09 36 59 71 50 55 57 18 43 44 45 33 80 91 92 99 61 62 63 64 69 70 68 74 66 73 Developmental disability - brain trauma Developmental disability - cerebral palsy Developmental disability ­ autism spectrum Developmental disability - mental retardation Developmental disability - epilepsy Developmental disability - other or unknown Family member of developmental disability client Severe emotional disturbance - child / adolescent Mental illness (excluding SPMI) Serious and persistent mental illness (SPMI) Family member of mental health client Alcohol client Drug client Chronic alcohol or other drug client (includes SSI) Alcohol and other drug client Family member of alcohol and other drug client Intoxicated driver Gambling client Blind / visually impaired Hard of hearing Blind / deaf Deaf Physical disability / mobility impaired Other handicap Unmarried parent Victim of domestic abuse Regular caregiver of dependent person Frail elderly Abused / neglected elder Alzheimer's disease / related dementia Migrant Refugee Cuban / Haitian entrant Corrections / criminal justice client (adult only) Homeless Hurricane Katrina evacuee Hurricane Rita evacuee None of the above (codependent client only)

SPECIAL CHILDREN'S SERVICES CATEGORIES
CHIPS - abuse and neglect CHIPS - abuse CHIPS - neglect Family member of abused / neglected child JIPS - status offender Family member of status offender CHIPS - other Family member of CHIPS - other Delinquent Family member of delinquent

SOS DESK (608) 266-9198 8:00 - 11:30 A.M. and 12:30 - 4:00 P.M. or leave a voice mail message. E-mail Address: [email protected] FAX (608) 267-2437 HSRS Handbook and Terminal Operator's Guide: http://www.dhs.wisconsin.gov/HSRS/index.htm WI Department of Health Services Division of Enterprise Services F-20458I (Rev. 1/2009)

REFERRAL SOURCE (Field 12)
01 02 03 04 05 06 07 08 09 10 11 13 14 15 16 17

Self Family, friend, or guardian AODA program (includes AA, Al-Anon) Hospital, clinic, physician, health agency School, college IDP-court IDP-Division of Motor Vehicle (DMV) Probation and parole Other court, criminal or juvenile justice or law enforcement Employer, Employee Assistance Program (EAP) County social services IV drug outreach worker Other social services agencies or community referral Drug court OWI court--monitors the multiple OWI offender Screening Brief Intervention Referral Treatment (SBIRT)

EDUCATION AT TIME OF ADMISSION (Field 13)
Enter the two digit number of years. 01-11 Highest grade completed 12 High school diploma or GED 14 Some college or vocational / technical school; assoc. degree or voc. tech. degree 16 Bachelors degree 18 Advanced degree (Master's, Ph.D.)

SUBSTANCE PROBLEM (Field 25a - 25c) (Cont'd) SUBSTANCE PROBLEM AT DISCHARGE (Field 26)
15 Benzodiazepines (diazepam, flurazepam, chlordiazepoxide, clorazepate, lorazepam, alprazolam, oxazepam, temazepam, triazolam, clonazepam, halazepam, Rohypnol, etc.) Other tranquilizers (Meprobamate, Equanil, Miltown) Barbiturates (phenobarbital, Seconal, Nembutal, amobarbital, etc.) Other nonbarbiturate sedatives or hypnotics (methaqualone, Quaalude, glutethimide, chloral hydrate, ethchlorvynol, Placidyl, GHB, etc.) Inhalants (ether, glue, aerosols, solvents, gases, chloroform, nitrous oxide) Over-the-counter diet, alert, sleep aids, cough syrup Other

25 30 35 40 45 50

Outpatient, family intensive Outpatient, group regular Outpatient, group intensive Outpatient, in-home regular Outpatient, in-home intensive Emergency outpatient

(75.13) (75.13) (75.13) (75.13) (75.13) (75.05)

Hours Hours Hours Hours Hours Hours

16 17 18 19 20 21

SPC END REASON (Field 34)

FAMILY RELATIONSHIP (Field 14)

Marital / family / interpersonal relationships / social support system 1 Very frequent, positive contact 2 Frequent or more often, usually positive, contact 3 Occasional or more often, sometimes positive, sometimes negative contact 4 Contact is usually negative 5 Little or no contact

LIVING ARRANGEMENT AT ADMISSION (Field 16)
01 02

USUAL ROUTE OF ADMINISTRATION (Field 27a - 27c)
1 2 3 4 5 1 2 3 4 5

03 04 05 06 07

Street, shelter, no fixed address, homeless Adults, private residence or household; living alone or with others without supervision; includes persons age 18 and older living with parents Supported or semi-supervised residence Specialized facility with on-site supervision Other institution Jail or correctional facility Children under age 18 living with parents

Oral (by mouth swallowing) Smoking (inhale by burning / heating substance) Inhalation (inhale or snort through the nose or mouth without burning the substance) Injection (IV or intramuscular or skin popping) Other No use in the past month 1-3 days in the past month (less often than once a week) 1-2 days per week 3-6 days per week Daily

Not required for SPCs 703, 705, 603 and brief services. 01 Completed service - major improvement 02 Completed service - moderate improvement 03 Completed service - no positive change 04 Referred - to another nonalcohol / drug agency, program or service 05 Behavioral termination - staff / program decision to terminate due to rule violation 06 Withdrew - against staff advice 07 Funding / authorization expired 08 Incarcerated 09 Death 14 Referral to another AODA agency or program 15 Transfer to another AODA service within an agency or program 16 Funding / authorization expired, same service reopened

CLOSING STATUS (Field 35)

USE FREQUENCY (Field 28a - 28c)

Not required for SPCs 703, 705, 603 and brief services. A = AODA = Frequency of alcohol / drug use during two weeks prior to discharge. 1 No use (abstinent) 2 1-3 days / month (less often than once a week) 3 1-2 days / week 4 3-6 days / week 5 Daily F = FAMILY = Marital / family / interpersonal relationships or social support system 1 Very frequent positive contact 2 Frequent, usually positive contact 3 Occasional, sometimes positive, sometimes negative contact 4 Contact is usually negative 5 Little or no contact E = EMPLOYMENT STATUS AT DISCHARGE 1 Employed full-time 2 Employed part-time 3 Unemployed, looking for work 4 Unemployed, not looking for work 5 Not in the labor force ­ homemaker 6 Not in the labor force ­ student 7 Not in the labor force ­ retired 8 Not in the labor force ­ disabled 9 Not in the labor force ­ inmate of jail, prison, or other institution AR = ARRESTS = Number of arrests 30 days prior to discharge, or since admission if less than 30 days LA = LIVING ARRANGEMENT AT DISCHARGE 01 Street, shelter, no fixed address, homeless 02 Private residence or household; living alone or with others without supervision; includes persons age 18 and older living with parents 03 Supported or semi-supervised residence 04 Specialized facility with on-site supervision 05 Other institution 06 Jail or correctional facility 07 Child under age 18 living with parents

BRIEF SERVICES (Field 17)
If an episode will only involve any of the following services, brief service may be coded Yes. 301 Court intake studies 501 Crisis intervention 507 / 50 Outpatient, emergency regular 507 / 65 Medication management 601 Outreach 602 Information and referral 603 Intake assessment

STANDARD PROGRAM CATEGORY / SUBPROGRAM (Field 30)
Note: Any other appropriate SPCs from CORE associated with alcohol and other drug abuse services should be reported even though not listed here. UNITS SPC/SUB STANDARD PROGRAM TO BE CODE CATEGORY NAME REPORTED Detox 703 10 Medically managed inpatient detox (75.06) Days 20 Medically monitored residential detox (75.07) Days 50 Ambulatory detoxification (75.08) Hours 705 10 Residential intoxification monitoring (75.09) Days Residential 503 50 Medically managed inpatient (75.10) Days 60 Medically monitored hospital (124, 75.11) Days treatment 70 Medically monitored CBRF (83, 75.11) Days treatment 504 Residential care center Days 506 10 Transitional residential-hospital (124, 75.14) Days setting 20 Transitional residential (83, 75.14) Days 203 Foster home Days 204 Group home Days Ambulatory 507 00 Outpatient, regular (75.13) Hours 05 Outpatient, intensive (75.13) Hours 65 Medication management Hours 70 Methadone or narcotic detox Hours 75 Methadone maintenance or narcotic (75.15) Hours treatment 603 Intake assessment Hours 509 Community support Hours 510 Comprehensive community services Days 704 10 Day treatment (75.12) Hours 112 55 Specialized medical supplies Items Note: The following optional subprograms may be used in place of 00 and 05 if the agency wants the additional detail. 507 10 Outpatient, individual regular (75.13) Hours 15 Outpatient, individual intensive (75.13) Hours 20 Outpatient, family regular (75.13) Hours

EMPLOYMENT STATUS (Field 18)
1 2 3 4 5 6 7 8 9

Employed full-time - 35 or more hours a week. Includes those working both full and part-time jobs Employed part-time - less than 35 hours a week Unemployed - looking for work in the past 30 days; includes registering for unemployment and on layoff from job Unemployed - not looking for work in the past 30 days Not in the labor force ­ homemaker Not in the labor force ­ student Not in the labor force ­ retired Not in the labor force ­ disabled Not in the labor force ­ inmate of jail, prison, or other institution

SUBSTANCE PROBLEM (Field 25a - 25c) SUBSTANCE PROBLEM AT DISCHARGE (Field 26)
01 02 03 04 05 06 07 08 09 10 11 12 13 14

None Alcohol Cocaine / crack Marijuana / hashish / cannabis / THC Heroin Nonprescription methadone Dilaudid / hydromorphone Other opiates and synthetics (codeine, morphine, oxycodone, demerol, opium, fentanyl, oxymorphone, etc.) PCP (phencyclidine) LSD Other hallucinogens (MDA, MDMA-ecstacy, peyote, mescaline, psilocybin, psilocin, STP, ketamine) Methamphetamine / ice; methcathinone / cat Other amphetamines (benzedrine, speed, dexedrine, methedrine, ritalin, preludin, and any other amines and related drugs) Other stimulants (phentermine, benzphetamine, mazindol, phendimetrazine, pemoline, chlortermine, etc.)

TARGET GROUP (Field 36) (Optional)
04 05 17 18 74 Alcohol abuse Drug abuse Intoxicated driver Alcohol and other drug abuse Family member / other of AODA client