Minimum Data Set (Client Profile, Intake & Admission) Admission Type Dependent Care During Tx Client Profile (Client Information) First Name (Full Name) Admission Date (First Treatment) Admission (Substance Abuse) Last Name (Full Name) SA Tx Admissions (In lifetime) Substance (1, 2 & 3) Gender SA Hospitalizations (6 Months) Frequency of Use (1, 2 &3) Date of Birth Prior MH Tx Admissions (12 Months) Method (1, 2 & 3) SSN (Full SSN) Prior MH Hospitalizations (2 Years) Detailed Drug Code (1, 2, & 3) Consent Decree (Class Member) Med. Tx Physician/Clinic (12 Months) Age of First Use (1, 2, & 3) Ethnicity Hospital ER (12 Months) Medication Assisted Treatment Type Race Med. Hospital Inpatient (12 Months) Admission (Tobacco) Veteran Status Other Med. Tx Locations (12 Months) Current Tobacco Use MH/MR Diagnosis Age of First Use (If Yes) Intake County Education Status Frequency of Use (30 days if Yes) Source of Referral Domestic Violence Survivor Route of Administration (If Yes) Initial Contact Date (First Phone Call) Self-Help Attendance (30 Days) Admission (Legal) Intake Date (First Face to Face) Gambling Frequency (Lifetime) Legal Status Pregnant (If Female) Financial Problems (If Yes) Domestic Violence Offender Due Date (If Female) Number of Arrests (12 Months) Admission (Financial/Household) Prenatal Treatment (If Female) Employment Status Number of Arrests (30 Days) HIV Primary Income Source Number of OUI Arrests (12 Months) Hep C Expected Payment Source Treatment to Satisfy DEEP IV Drug User Insurance Type DEEP Status (If Yes) Shared Needles (If IVDU) Living Arrangements Admission (Program Enrollment) Problem Area Marital Status Program Name Number of Dependents (Age Group) Start Date (Admission Date) Admission (Profile) Minimum Data Set (Encounters, Program Disenrollment, Discharge) Discharge (Encounters/Units) Start Date (Admission Date or Month) Service (Unit Type - Individual, Group, Etc.) Number of Units or Sessions Program Name Charge Per Unit
Minimum Data Set (Client Profile, Intake & Admission) Client Profile (Client Information) First Name (Full Name) Last Name (Full Name) Gender Date of Birth SSN (Full SSN) Consent Decree (Class Member) Ethnicity Race Veteran Status Intake County Source of Referral Initial Contact Date (First Phone Call) Intake Date (First Face to Face) Pregnant (If Female) Due Date (If Female) Prenatal Treatment (If Female) HIV Hep C IV Drug User Shared Needles (If IVDU) Problem Area Admission (Profile) Admission Type Admission Date (First Treatment) SA Tx Admissions (In lifetime) SA Hospitalizations (6 Months) Prior MH Tx Admissions (12 Months) Prior MH Hospitalizations (2 Years) Med. Tx Physician/Clinic (12 Months) Hospital ER (12 Months) Med. Hospital Inpatient (12 Months) Other Med. Tx Locations (12 Months) MH/MR Diagnosis Education Status Domestic Violence Survivor Self-Help Attendance (30 Days) Gambling Frequency (Lifetime) Financial Problems (If Yes) Admission (Financial/Household) Employment Status Primary Income Source Expected Payment Source Insurance Type Living Arrangements Marital Status Number of Dependents (Age Group) Dependent Care During Tx Admission (Substance Abuse) Substance (1, 2 & 3) Frequency of Use (1, 2 &3) Method (1, 2 & 3) Detailed Drug Code (1, 2, & 3) Age of First Use (1, 2, & 3) Medication Assisted Treatment Type Admission (Tobacco) Current Tobacco Use Age of First Use (If Yes) Frequency of Use (30 days if Yes) Route of Administration (If Yes) Admission (Legal) Legal Status Domestic Violence Offender Number of Arrests (12 Months) Number of Arrests (30 Days) Number of OUI Arrests (12 Months) Treatment to Satisfy DEEP DEEP Status (If Yes) Admission (Program Enrollment) Program Name Start Date (Admission Date) Minimum Data Set (Encounters, Program Disenrollment, Discharge) Discharge (Encounters/Units) Service (Unit Type - Individual, Group, Etc.) Program Name Start Date (Admission Date or Month) Number of Units or Sessions Charge Per Unit
WITS-AD-DC-Manual-Aug2017.docx