Substance Abuse Detoxification Services

Intake Report

GENERAL INFORMATION SECTION

Intake Number

• Each Detoxification Services Intake Report documented in CMBHS has a unique number generated by the system.
• This number is view only and can not be changed by the User.

Intake Date

• This field is used to record the date that the client was evaluated. It will default to today’s date.
• If the Intake occurred on some other date before today’s date, the user can change this field to the correct date. A future date can not be entered.
• If the Intake interview occurred on more than one day, enter the first date that the Intake interview began.
• When you enter the date, you must use one of the following processes:
• Enter the eight (8) numbers of the date (mmddyyyy) with no spaces or punctuation, including the leading zeros (0) for any days and months that are single digit, and CMBHS will automatically reformat and display the date as mm/dd/yyyy.

OR

• Enter the eight (8) numbers of the date with forward slashes between the month, day and year (mm/dd/yyyy).
• CLICK IN the text box and begin typing.

 

Intake Type

This field will automatically fill according to the Intake Type, Initial, or Discharge, that you chose from the toolbar on the left side of your page, when you first started the Intake.

• This is a view-only field and you can not change the Intake Type from this page.

 

Referred by Detoxification Services

This field is used to document who referred the client to the provider for services.

• If a screening was completed on the client within the last 30 days, this question will automatically be answered with the information that was entered for this same question in the screening. It can not be changed by the user.
• If a client screening was not completed within 30 days, the field will display as blank and the user must select an answer.

 

The answer choices to this question are below. Additional information for the answer choices can be found in the Glossary section.

• 12-step Program
• Attorney
• Battered Women’s Center
• City/County Health Services
• Civil Court
• Clergy
• Commitment
• Council on Alcohol and Drug Abuse
• Correctional Facility
• Court Services
• Court/DWI/DUI
• Court/Pre-trial Diversion
• Department Family Protective Services (DFPS-CPS)
• Department of Assistive and Rehabilitative Services (DARS)
• Domestic Violence Program
• Drug Court
• Employee Assistance Program (EAP)
• Employer
• Family Member
• Friend
• Halfway House/Intermediate Care
• Health Professional
• Hospital/General
• Hospital/Psychiatric
• Hospital/State Psychiatric
• Hospital/Veterans Administration (VA)
• Mental Health Community Center
• Mental Health/Day Treatment
• Mental Health/Out-patient
• Mission/Shelter for HomelessA person is homeless when he/she resides in one of the following: places not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings, under bridges; an emergency shelter; transitional housing for homeless persons; a person who is being evicted within a week from a private dwelling or institution, no residence has been identified and lacks resources to obtain housing, or is fleeing a domestic violence housing situation and no subsequent residence has been identified and lacks the resources and support networks needed to obtain housing.
• Nursing Home
• Other
• Other Community Referral
• Other Health Care Provider
• Outreach Program
• Parole
• Police
• Prevention Program
• Probation
• School/Based Services
• School/Counselor
• School/Principal
• School/Student Assistance Program (SAP)
• School/Teacher
• Self (Client)
• Social Security Administration
• Substance Abuse Treatment/Detox Facility
• Substance Abuse Treatment/Out-patient, Day
• Treatment, Other Non-Residential
• Substance Abuse Treatment/Residential Program
• Substance Abuse/Aftercare Program
• Substance Abuse/OSAR
• Texas Workforce Commission (TWC) Texas Youth Commission (TYC)
• Treatment Alternative to Incarceration (TAIP) Youth Shelter

 

Interviewer

Detoxification ServicesThe name of the CMBHS user who first created the Intake Report will display in this field as the default.

• If the name that displays is not that of the person who interviewed the client, the name must be changed.
• CLICK ON the drop down menu to search for the name of the person who interviewed the client.
• Select the name by highlighting it and CLICKING ON the name.

 

EDUCATIONAL & EMPLOYMENT TAB

Information about the client’s educational and employment history and current status are documented in this section.

 

What grades has the client completed?

• “Grades completed” means grades the client finished.
• Traditional schooling and structured home-based schooling are also included.
• If the client has a GED enter 12 as the grades completed. If the client has a bachelor’s degree document 16 and a master’s degree 18.
• To document your answer to this question, TYPE the grade number in the box. You may only enter numbers.

 

What is the client's employment status?

• Select the answer that best represents the client’s current employment status.
• Click on the arrow to the right of the box to see the answer choices.
• Highlight and CLICK ON your selection.
• Enter the months in numbers.
• CLICK IN the box to begin typing. The answer choices for this question are:
  • Full time employed – Is employed on a fulltime basis. Full time is 40 hours per week or the standards number of hours for a certain job type.
  • Part-time employed - Is employed on a less than fulltime basis.
  • Unemployed – The client has been employed in the past, is not currently employed and is seeking employment. May or may not be receiving unemployment benefits.
  • Not in the labor force – The client is not currently employed, is not collecting unemployment benefits and is not looking for work.
  • Unknown – The client is not able to provide information.

 

What is the reason the client is not in the labor force?

• Homemaker
• Student
• Retired
• Receiving SSI/SSDI and can not keep a job
• Receiving SSI/SSDI and worries
• Inmate of institution
• Does not want or need work
• Unable to find or
• Other Unknown

 

Usual or last occupation?

• CLICK IN the box and begin typing.
• You may enter letters and numbers.

 

How many months was the client employed during the last 12 months?

• In answering this question, consider all employment, full or part time.
• Enter the months using numbers.
• CLICK IN the box to begin typing.

 

Is the client a veteran?

• Indicate if the client is a past member of the United States of America Military Armed Forces. Include any branch of service
• CLICK IN the Yes or No circle to answer. A GREEN dot will appear in the circle.

 

Military discharge status?

• Honorable Discharge
• Other than Honorable Discharge
• Bad Conduct Discharge
• Dishonorable Discharge
• Entry Level Separation
• Commissioner Officer dismissal

 

What is the client's source of income/support?

• This field is used to document the client’s primary source of financial support. If the client has more than one source of employment, identify the one identified by the client as primary. • You may select only one answer choice.
• The answer choices for this question are:
  • Wages/Salary – This is money earned by the client through engaging in some kind of employment, legal or otherwise.
  • Public Assistance – Any income or support assistance provided to the client by a governmental or non-profit agency based on need.
  • Retirement/Pension – Income or support provided to the client based retirement from previous employment.
  • Disability - Income or support provided to the client based on medical determination of a disability.
  • Other – If you select Other, you must complete the next question as well.
  • None – Client claims (and there is no evidence of) any regular access to a source of income/support.
  • Unknown – Select Unknown if no information regarding the client’s income or support is available
• If you select Other, the following question displays:
  • Other source of income/support?
    • This question will only display if you select Other as a response to the question above.
    • Document the client’s source of income.
    • CLICK IN the box and begin typing.

FAMILY/SOCIAL TAB

These questions are used to document information about the client’s living situation, family and social situation.

What is the client's current living situation?

• Select the answer that best describes where the client is currently living. You may select only one answer. The answer choices for this question are:
  • Independent
  • Dependent in Family Home
  • Support Housing
  • Group Home
  • Assisted Living
  • Treatment/Training - Rehabilitation Center
  • Nursing Home
  • Intermediate Care Facility(ICF)
  • Hospital
  • Homeless
  • Correctional Facility

 

What is the client's marital status?

• This question is used to document the client’s current marital status. The answer choices for this question are:
  • Currently married
  • Divorced
  • Never Married
  • Widowed
  • Separated

Children under 18 in Client's Household

Does the client need childcare services in order to participate in services?

• Determine if the client needs child care in order to attend and participate in detoxification services.
• CLICK IN the Yes or No circle to answer. A GREEN dot will appear in the circle. 

 

Is the client formally seeking to regain custody of children?

• If the client’s children are in the custody of the Department of Protective and Regulatory Services (DPRS - CPS), is the client working with DPRS to regain custody of the children.
• CLICK IN the Yes or No circle to answer. A GREEN dot will appear in the circle. 

LEGAL TAB

What is the client's legal status?

• CLICK IN the Yes or No circle to answer. A GREEN dot will appear in the circle. 
•  The answer choices for this question are:
•  Awaiting Trial
•  Awaiting Sentencing
• Pre-trial Diversion/Deferred Prosecution
•  Probation (DWI)
• Probation (non-DWI)
• Parole

MEDICAL TAB

This section is used to document the client’s medical history and current health status. To document in this section, begin with the General Health questions.

Is the client Pregnant?

• This question is displayed only when the client being screened is female.
• The answer choices are Yes, No or Unknown.
• If the client answers No to this question, ask how she can be certain she is not pregnant. If there is any question regarding the reliability of the information, select Unknown.
• To document the client’s response to this question, CLICK ON the Yes, No or Unknown button matching the client’s answer.

Allergies and Adverse Drug Reactions

In this section, any allergies or adverse reactions the client has experienced are documented. The information entered in this section will also display on the Client’s Workspace, in the Allergies and Adverse Drug Reactions section.

If the client has any allergies or adverse drug reactions, it is important that they be documented here and updated whenever the client provides new information or an incident is observed during the course of treatment.

NONE - If the client has no known allergies and has not experienced an adverse drug reaction, then CLICK IN the None box. This will hide all the other questions about allergies and “There are no recorded allergies and Adverse Drug Reactions” will display in the table.

 

Substance In the Allergies and Adverse Drug Reactions box, you may add as many Substances and Descriptions of Reactions as needed.

• Be sure to ask the client about any foods, medications (over the counter, street drugs and/or prescription), insects, cosmetics, cleaners, etc to which they may have had allergic or adverse reactions to.
• Review any prior records for additional allergy and drug reaction information.
• CLICK IN the box and TYPE in the information.

Description of Reaction

• Include the client’s own words as much as possible when describing the reaction.
• CLICK ON the Add button when you have completed entering information into the fields.

Prescribed Current Medication

• Document the client’s current prescribed medications, any over the counter medications, herbal supplements or vitamins in this section,
• If the client is taking prescribed medications, CLICK IN the Medications text box and begin typing the first few letters of the medications name. As soon as you begin to do this, a list of medications will appear. Continue typing until you see the medication you need. When you see the medication, CLICK ON it to highlight and select it.
• After you select the medication, the page will refresh (note the progress bar at the top of the page) and the medication information will appear in the text box in a different font.
• The medication information may include the Generic or brand name of the medication, information about the active or inert ingredients)

Form

• Form is the physical form in which a drug is produced and dispensed, such as a tablet, a capsule, or an injectable.
• The forms that display in this field are from an FDA data base.

 

Type

• The answer choices for this question are:
  • Over the Counter
  • Herbal
  • Vitamins
  • Other provider
  • Other

 

Strength

• The strength of a drug product tells how much of the active ingredient is present in each dosage.
• The strengths that display in this field are from an FDA data base.

 

Dosage

• Enter a numeric dosage in the Dosage box, indicating the number of units to be given. This is not the same as the dosage strength.
  • Example 1: An order stating “50mg Promethazine” could be entered as “Promethazine Hcl tablet, 25mg, 2, whole” to equal 50mg.
  • Example 2: Similarly, an order for 12.5mg Promethazine could be entered “Promethazine Hcl tablet, 25mg, 1, half” which is equal to the 12.5mg Promethazine ordered.

 

Dosage Unit

• In the Dosage Unit field, TYPE in the unit to be used. This will vary based on what forms the medication is available in. Tablets and capsules will generally be indicated in whole, half, or another fraction of a unit, while other medications will list units such as weights, volumes or other dosage units.

 

Route

• Route of administration is a way of administering a drug to a site in a patient.
• The strengths that display in this field are from an FDA data base.
• If the information requested by this field is unknown, leave “None Selected” as the answer.

 

Frequency

• Frequency is how often the medication is to be taken.
• The strengths that display in this field are from an FDA data base.
• If the information requested by this field is unknown, leave “None Selected” as the answer.

 

Next

When you have finished entering documentation for Prescribed Medications,

1. CLICK “Add” button on the right hand side of the page.

• The Page will refresh and the medications will be documented in the table.
• Additional entries can be made until there are more medications.

To change a previously-entered answer,

1. Select the appropriate row and use the mouse to select “Edit.”The page will refresh and display the previously recorded information.
2. CLICK IN the box and change the answer.
3. Then select “Add” to update the change.

To remove a previously-entered answer,

1. select the appropriate row and select “Remove.” The page will refresh and the answer will be struck out with a line.

To restore a removed answer,

1. select a struck out row and use the mouse to select “Restore”. The screen will refresh and only the new answers will display.

When you have finished entering documentation for Prescribed (Current) Medications,

• Use the mouse to click the Add button on the right hand side of the page.
• The Page will refresh and the medications will be documented in the table.

 How many times in the past 12 months has the client been in a general hospital including the emergency room?

• Determine the total number of hospitalizations and emergency rooms visits for the last 12 months for the client. To document the client’s response to this question, TYPE IN the number of times the client says they have been in a general hospital.

Substance Abuse Section

If the client uses one drug, answer the Primary Use questions and select None for each of the Secondary or Tertiary drug questions.

Route

• Route of administration is a way of administering a drug to a site in a patient.
• The strengths that display in this field are from an FDA data base.
• If the information requested by this field is unknown, leave “None Selected” as the answer.

  Frequency of Use

  • Document how frequently the client uses this drug by selecting one of the answer choices from the drop down list.
  • The answer choices for this question are:

  • No use in past month
  • 1-3 times in the past month
  • 1-2 times in the past week
  • 3-6 times in the last week
  • Daily
  • Unknown

  • What was the client’s age when they first used this drug?
    • Enter the age in years.
    • TYPE the client’s age in years, into the text box.

   

  Last Date Used 

  • Document the date the client last used this drug.
  • You may enter 8 numbers into the text box and CMBHS will put the numbers into the correct date format or you may enter the date in this format, mm/dd/yyyy.

 How many years (any use at all)?

• To answer this question, count the number of years the client has used this drug since they first started, minus any years they were abstinent from the drug.
CLICK HERE for examples of how to answer this question.
EXAMPLE 1:
• The client first began using alcohol at age 15 and is now 30 years old. 
• The client has continually used alcohol since starting until the last date used (which is today’s date when he seeks treatment.) 
• The total number of years the client has used alcohol is 15. 
• The clinician documents 15 years.
EXAMPLE 2:
• The client first began using methamphetamines at age 25. 
• The client used for 2 years and then went into treatment. 
• The client did not use methamphetamines for 5 years. 
• Last year the client began using methamphetamines again. 
• The client has used methamphetamines for a total of 3 years. 
• The clinician documents 3 years.
EXAMPLE 3:
• The client first began using Opioid pain medications at age 50, following back surgery. 
• After about 6 months his physician stopped prescribing the medication. 
• The client found other ways to get the medication and started taking much more than had been originally prescribed.   The client continued for 4 years and then went into treatment. 
• The client did not use for 2 years and then 6 months ago started again. 
• The client has used for a total of 5 years.  The clinician documents 5 years.

NOTE:

Do NOT leave Blank.

Route of Administration

This means how does the client get the drug into their body.

• CLICK ON the blue arrow symbol to the right of the drop down box and select your answer by CLICKING ON it.
• The answer choices are:

• Oral
• Unknown
• Other
• Nasal Inhalation
• Smoking
• Injection

• CLICK ON the blue arrow to the right of the drop down box and select your answer by CLICKING ON it.
• If the client uses more than one route of administration, select the most frequently used route. If you select Other, this additional question will display:

Other Substance Route?

• Use the text box to document the other route of administration used by the client.
• CLICK in the text box and type in your answer.

Frequency of Use

• Document how frequently the client uses this drug by selecting one of the answer choices from the drop down list.
• CLICK on the blue arrow to display the answer choices.

The answer choices for this question are:

• No use in past month
• 1-3 times in the past month
• 1-2 times in the past week
• 3-6 times in the last week
• Daily
• Unknown

Age at First Use

• Document the client’s age when they first used this drug.
• TYPE the client’s age in years, into the text box.

Last Date Used 

• Document the date the client last used this drug.
• You may enter 8 numbers into the text box and CMBHS will put the numbers into the correct date format or you may enter the date in this format, mm/dd/yyyy.

How many years (any use at all)?

• To answer this question, count the number of years the client has used this drug since they first started, minus any years they were abstinent from the drug.

Tertiary Use Substance

• If the client uses a tertiary (third) substance, select the tertiary substance used by the client from the drop down list.
• If the client does not use a tertiary substance, select None from the drop down.

NOTE:

Do NOT leave Blank.

 Route of Administration

This means how does the client get the drug into their body.

• CLICK ON the blue arrow symbol to the right of the drop down box and select your answer by CLICKING ON it.
• The answer choices are:

• Oral
• Unknown
• Other
• Nasal Inhalation
• Smoking
• Injection

Frequency of Use

• Document how frequently the client uses this drug by selecting one of the answer choices from the drop down list.
• CLICK on the blue arrow to display the answer choices.

The answer choices for this question are:

• No use in past month
• 1-3 times in the past month
• 1-2 times in the past week
• 3-6 times in the last week
• Daily
• Unknown

Age at First Use

• Document the client’s age when they first used this drug.
• TYPE the client’s age in years, into the text box.

Last Date Used 

• Document the date the client last used this drug.
• You may enter 8 numbers into the text box and CMBHS will put the numbers into the correct date format or you may enter the date in this format, mm/dd/yyyy.

How many years (any use at all)?

• To answer this question, count the number of years the client has used this drug since they first started, minus any years they were abstinent from the drug.

In the past 30 days, how many days has the client been abstinent from all substances?

• Enter the number of days in the past 30 days that the client says they have been abstinent from all substances.
• This means days that they have not used any drugs or alcohol.
• CLICK IN the box and enter the number of days.

How many times has the client been treated for a substance use disorder?

• Include all types of treatment for a substance use disorder. Do not include visits to the Emergency Room for overdoses or other emergency complications from alcohol and/or other drugs.
• Enter the number of times the client received treatment (treatment episodes) in the text box.

How many days has the client attended community-based mutual help groups for alcohol and/or other drugs in the past 30 days? Detoxification Services Does the client use tobacco on a daily basis?

• Tobacco use includes cigarettes, cigars, tobacco smoked in a pipe, snuff, chew, and any other tobacco products.
• CLICK ON Yes or No to document your answer to this question.

DIAGNOSIS

In this section of the Assessment, the clinician documents the client’s diagnosis across all 5 axis.

How To Document a Diagnosis – the following are general instructions for documenting a diagnosis on each of the 5 axis.

To Search by Diagnosis

• To document a diagnosis, you must first find the diagnosis in the CMBHS database. Start by CLICKING ON the New Axis (I, II, III, IV, V) button.
• Then CLICK IN the Diagnosis text box and begin typing the first few letters of the diagnosis. A menu box will drop down and display all the diagnoses that begin with those letters.
• If needed, SCROLL through the list to see all the search results. CLICK ON your selection to highlight it. Then CLICK ON the Select button at the bottom of the list.

To Search by Code

• You may also search the Diagnoses lists by using the code (numbers) that correspond to each diagnosis.
• TYPE one or more numbers into the text box.
• When the results are displayed, the word More will be at the bottom of the list. CLICK ON the word More and the diagnoses that contains your search number(s) will display.
• CLICK ON and highlight your selection, then CLICK ON the Select button at the bottom of the list. The diagnosis you have selected will be inserted into the textbox.

Ranking the Diagnoses

• Before you begin documenting the diagnoses under Axis II, determine a rank for all the diagnoses under Axis II.
• Enter the primary diagnosis first, then the secondary diagnosis second etc. This will eliminate the need for changes and corrections later.
• After you have added a diagnosis to the table, you may edit, change the rank and remove a diagnosis from the list.

Making Changes to the Diagnoses

To “Change” a previously-entered answer, select the appropriate row and then select “Edit.”

• The page will refresh and display the previously recorded information.
• The user may change the answers by CLICKING IN the box and changing the answer.
• Then select “Add” to update CMBHS.

 

To "Remove" a previously-entered answer, select the appropriate row and select “Remove.”

• The screen will refresh and the answer will be struck out with a line.

To Restore a removed answer, select a struck out row and use the mouse to select “Restore”.

• The screen will refresh and only the new answers will display.

NOTE:
After you select information from the 'Diagnosis' and 'Justification' drop-downs lists, always remember to CLICK ON the ' Add ' button.
If you do not CLICK ON the ' Add ' button, your selections will not be entered to the table and all the information will need to be re-entered before you can Save the Assessment.
If the clinician determines that the client does not have a condition or disorder requiring documentation on a specific axis, select “No Diagnosis or Condition on Axis - V71.09” as the diagnosis.
If you are unsure of the diagnosis or not qualified to make a diagnosis then use “Diagnosis Deferred on Axis - 799.9.

AXIS I - Clinical Disorders, most DSM V codes and conditions that need clinical attention.

• Before you begin documenting the diagnoses on Axis I, determine the rank of the Axis I diagnoses so you can document them in the correct order. The first Diagnosis you document will be the primary and designated as #1. The second you document will be designated as #2 etc. You can change the order of the diagnoses after they are entered but entering them in the correct order eliminates the need for change.
• After you have added a diagnosis to the table, you may edit, change the rank and remove a diagnosis from the table.
• You must document an appropriate Substance Abuse diagnosis on AXIS I for the client to be eligible for Substance Abuse services.

Justification:

• Select one of the following answer choices that best represents the justification for the diagnosis.
  • By Client Report
  • By Clinical Observation
  • By Collateral Report
  • By History
  • By Impression
  • By Physician Report

What's Next?

• After selecting the justification, CLICK ON the Add button on the right hand side of the page. The Page will refresh and the diagnosis and justification will appear in the AXIS I table.
• You may ADD as many diagnoses as needed.
  • NOTE: After you select answers from the 'Diagnosis' and 'Justification' drop-downs lists, always remember to CLICK ON the Add button. If you do not CLICK ON the Add button, your selections will not be entered to the table and all the information may need to be re-entered before you can Save the document.
  • NOTE: If the clinician determines that the client does not have a condition or disorder requiring documentation on a specific axis, select “No Diagnosis or Condition on Axis - V71.09” as the diagnosis.

AXIS II - Personality and Developmental Disorders

• If you are unsure of the diagnosis or not qualified to make a diagnosis, you may use “Diagnosis Deferred on Axis - 799.9.” To select this option, CLICK IN the box and a green check mark will appear.
• If the client has one or more Axis II diagnoses, select one or more of the following:
  • Antisocial Personality Disorder - 301.7
  • Avoidant Personality Disorder - 301.82
  • Borderline Personality Disorder - 301.83
  • Dependent Personality Disorder - 301.6
  • Diagnosis Deferred on Axis II - 799.9
  • Histrionic Personality Disorder - 301.5
  • Mental Retardation, Severity Unspecified - 319
  • Mild Mental Retardation - 317
  • Moderate Mental Retardation - 318.0
  • Narcissistic Personality Disorder - 301.81
  • No Diagnosis or Condition on Axis II - V71.09
  • Obsessive-Compulsive Personality Disorder - 301.4
  • Paranoid Personality Disorder - 301
  • Personality Disorder NOS - 301.9
  • Profound Mental Retardation - 318.2
  • Schizoid Personality Disorder 301.2
  • Schizotypal Personality Disorder - 301.22
  • Severe Mental Retardation - 318.1 Severity Unspecified
• Justification:

• Select one of the following answer choices that best represents the justification for the diagnosis.
  • By Client Report
  • By Clinical Observation
  • By Collateral Report
  • By History
  • By Impression
  • By Physician Report

What's Next?

• When you have finished entering all the Diagnoses for this Axis, use the mouse to click the Add button on the right hand side of the page. The Page will refresh and the diagnosis and justification will appear in the AXIS I table.
• Additional entries can be made until there are no more Diagnoses.
• To Change a previously-entered answer, select the appropriate row and use the mouse to select Edit. The page will refresh and display the previously recorded information. The user may change the answers by CLICKING IN the box and changing the answer. Then select Add to update CMBHS.
• To remove a previously-entered answer, select the appropriate row and select the Remove Button. The screen will refresh and the answer will be struck out with a line.
• To restore a removed answer, select a struck out row and use the mouse to select the Restore button. The screen will refresh and only the new answers will display.
  • NOTE: After you select information from the 'Diagnosis' and 'Justification' drop-downs lists, always remember to CLICK ON the Add button. If you do not CLICK ON the Add button, your selections will not be entered to the table and all the information will need to be re-entered before you can Save the Intake.
  • NOTE: If the clinician determines that the client does not have a condition or disorder requiring on a specific axis, select “No Diagnosis or Condition on Axis - V71.09” as the diagnosis.

AXIS III - General Medical Conditions

• If you are unsure of the diagnosis or not qualified to make a diagnosis then use “Diagnosis Deferred on Axis - 799.9.”
• Before you begin documenting the diagnoses under Axis III, determine the rank of the diagnosis and document them in that order. This will eliminate the need for changes and corrections later.
• After you have added a diagnosis to the table, you may edit, change the rank and remove a diagnosis from the list.

To Search for a Diagnosis

• CLICK IN the Diagnosis text box and begin typing the first few letters of the diagnosis.
• A menu box will drop down and display all the diagnoses that begin with those letters. CLICK ON and highlight your selection.
• You may also search by the diagnostic code.

Justification

• Select one of the following answer choices that best represents the justification for the diagnosis.
  • By Client Report
  • By Clinical Observation
  • By Collateral Report
  • By History
  • By Impression
  • By Physician Report
  • After selecting the justification, CLICK ON the Add button. The diagnosis and justification will appear in the AXIS III Table below.
  • You may ADD as many diagnoses as needed.

Next

• When you have finished entering all the Diagnoses for this Axis, use the mouse to click the Add button on the right hand side of the page. The Page will refresh and the Diagnoses will be documented in the table.
• Additional entries can be made until there are no more Diagnoses.
• To “Change” a previously-entered answer, select the appropriate row and use the mouse to select “Edit.” The page will refresh and display the previously recorded information. The user may change the answers by CLICKING IN the box and changing the answer. Then select Add to update CMBHS.
• To remove a previously-entered answer, select the appropriate row and select “Remove.” The screen will refresh and the answer will be struck out with a line.
• To restore a removed answer, select a struck out row and use the mouse to select “Restore”. The screen will refresh and only the new answers will display.
  • NOTE: After you select information from the 'Diagnosis' and 'Justification' drop-downs lists, always remember to CLICK ON the Add button. If you do not CLICK ON the Add button, your selections will not be entered to the table and all the information will need to be re-entered before you can Save the Intake.
  • NOTE: If the clinician determines that the client does not have a condition or disorder requiring documentation on a specific axis, select “No Diagnosis or Condition on Axis - V71.09” as the diagnosis.
• If you are unsure of the diagnosis or not qualified to make a diagnosis then use “Diagnosis Deferred on Axis - 799.9.”

AXIS IV Psychosocial and Environmental Problems.

• Check all that are clinically significant by CLICKING IN the box in front of the answer choice.

The answer choices for this question are:

• Problems with primary support group
• Social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to health care
• Problems in interaction with legal services
• None
• Other Psychosocial and Environmental Problems

• If you select Other Psychosocial and Environmental Problems as an answer choice a text box labeled Other Diagnosis will display.
• Other Diagnosis
  • Explain the nature of the other psychosocial and environmental problems here.
• CLICK IN the box and type in the information.

AXIS V Global Assessment of Functioning Scale

• Enter the number that best represents the client’s level of functioning in the text box.
• The number must be between 0 to 100.
• CLICK HERE for more information about the Global Assessment of Functioning (GAF).

Priority Population Status (View Only)

• CMBHS will determine and display the Priority Population Status of the client based on the information that has been entered.
  • Pregnant injecting drug user
  • Pregnant substance abuser
  • Injecting drug user
  • Parent with children in foster care
  • Veteran with honorable discharges

 

Audit Information

• After the document has been Saved and added to the CMBHS database, the following Audit Information will show at the bottom of the page.
• This information is view only and cannot be changed by the user.
  • Created By The name of the user that first started the document will display here.
  • Created Date This is the date the document was first started.
  • Last Saved By The name of the user that last opened, edited and saved the document will display here. This field is updated each time the record is edited and saved.
  • Last Saved Date The date the document was last opened, edited and saved. This field is updated each time the record is edited and saved.

Next
You have answered the last question in the Detoxification Services Intake Report. Select one of the following next steps:
To Save what you have completed thus far and Stop Documenting. CLICK HERE for Instructions. Select a document status. CLICK HERE for information on the Document Status CLICK Save, CLICK Close.
If you want to Save what you have completed so far and then Continue Documenting CLICK HERE for Instructions. CLICK ON the Save and Continue button. CMBHS will save your data to the CMBHS database. Before it saves the data however, it will conduct an edit check to ensure that all the required fields have been filled properly. If the CMBHS system detects an error in the data entered, an Error Message will appear to inform you of the problematic field(s). When you get an error message, CLICK ON the OK button, and you will be taken to the field that requires correction. Correct the data entry error then CLICK ON the Save button again. After you have corrected all the errors, the Successfully Saved message will display. CLICK ON the Ok box and the document will close