Nc-toppsadatcepisodecompletion

NC-TOPPS
ADATC Episode Completion Interview
**Use this form for backup only. Enter data into web-based system. (https://nctopps.ncdmh.net/adatc.htm)
Clinician First Initial & Last Name
Consumer Record Number (HEARTS #)
7. Type of Discharge: (mark only one)
AA - Against Medical Advice Discharge (AMA)BP - Behavior Problem DischargeDC - Direct by Court Order Please provide the following information about
DI - Direct Discharge to Inpatient Commitment the individual:
1. Date of Birth
PC - Program Completion→ (skip to c. 'Conditions at Discharge')PR - Personal Reasons 2. Gender
TD - Therapeutic DischargeTX - Permanent Transfer Out to Other State Facility 3. County of Residence of the Individual:
Consumer Availability: (mark only one)
Consumer is Not Available/Already Been Discharged → (skip to b) 4. Level of care received:
Consumer is Available → (skip to c) b. Select the circumstance(s) as to why the consumer is not available:(mark all that apply) External: → (skip to 8a, if 'Death' - answer b-2) 5. For sub-acute individual only:
Type of treatment or service rendered since
the last assessment (TRACK):
Relapse Prevention Track/Recovery Solutions b-2. If individual has died, what is the death category? (mark only one) Skills Building Track/Recovery Dimensions AM - Death with Autopsy - Medical Examiner→ STOP - end of assessment DL - Death while on Leave or Visiting → STOP - end of assessment 6. Please select the appropriate disability
c. Conditions at Discharge: (mark only one) category for which the individual is receiving
services and supports. (mark only one)
DS - Direct to Substance Abuse Commitment 8a. Date of Discharge
8b. Discharge LME:
9. Please indicate the DSM-IV TR diagnostic classification(s) for this individual. (See Attachment I)
10. Special Populations (mark all that apply)
If consumer is not available/already been discharged, skip questions 11-13:
11. As you approach the end of this treatment episode, do you view your substance use history differently than reported at
admission?
Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 and 164. Consumer-identifyinginformation may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited.
Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
NC-TOPPS
ADATC Episode Completion Interview
**Use this form for backup only. Enter data into web-based system. (https://nctopps.ncdmh.net/adatc.htm)
12. Please indicate your Primary (required), Secondary
13. Upon discharge, where are you planning to live? (mark only one)
(if applicable), and Tertiary (if applicable)
substance problems by entering a "1" for Primary,
"2" for Secondary, and "3" for Tertiary.
14. Referred Services: (mark all that apply)
If consumer is not available/already been discharged, skip Socrates 8A and Socrates 8D:
(1) NO! Strongly Disagree (2) No Disagree (3) ? Undecided or Unsure (4) Yes Agree (5) YES! Strongly Agree
Socrates 8A - Ask questions to individual if Primary, Secondary, or Tertiary substance problem(s) include alcohol.
1. I really want to make changes in my drinking.
2. Sometimes I wonder if I am an alcoholic.
3. If I don't change my drinking soon, my problems are going to get worse.
4. I have already started making some changes in my drinking.
5. I was drinking too much at one time, but I've managed to change my drinking.
6. Sometimes I wonder if my drinking is hurting other people.
7. I am a problem drinker.
8. I'm not just thinking about changing my drinking, I'm already doing something about it.
9. I have already changed my drinking, and I am looking for ways to keep from slipping back
to my old pattern.
10. I have serious problems with drinking.
11. Sometimes I wonder if I am in control of my drinking.
12. My drinking is causing a lot of harm.
13. I am actively doing things now to cut down or stop drinking.
14. I want help to keep from going back to the drinking problems that I had before.
15. I know that I have a drinking problem.
16. There are times when I wonder if I drink too much.
17. I am an alcoholic.
18. I am working hard to change my drinking.
19. I have made some changes in my drinking, and I want some help to keep from going back to
the way I used to drink.
**Scoring automatically calculated online
Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 and 164. Consumer-identifyinginformation may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited.
Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
NC-TOPPS
ADATC Episode Completion Interview
**Use this form for backup only. Enter data into web-based system. (https://nctopps.ncdmh.net/adatc.htm)
(1) NO! Strongly Disagree (2) No Disagree (3) ? Undecided or Unsure (4) Yes Agree (5) YES! Strongly Agree
Socrates 8D - Ask questions to individual if Primary, Secondary, or Tertiary substance problem(s) include any type of drug.
1. I really want to make changes in my use of drugs.
2. Sometimes I wonder if I am an addict.
3. If I don't change my drug use soon, my problems are going to get worse.
4. I have already started making some changes in my use of drugs.
5. I was using drugs too much at one time, but I've managed to change that.
6. Sometimes I wonder if my drug use is hurting other people.
7. I have a drug problem.
8. I'm not just thinking about changing my drug use, I'm already doing something about it.
9. I have already changed my drug use, and I am looking for ways to keep from slipping back to
my old pattern.
10. I have serious problems with drugs.
11. Sometimes I wonder if I am in control of my drug use.
12. My drug use is causing a lot of harm.
13. I am actively doing things now to cut down or stop my use of drugs.
14. I want help to keep from going back to the drug problems that I had before.
15. I know that I have a drug problem.
16. There are times when I wonder if I use drugs too much.
17. I am a drug addict.
18. I am working hard to change my drug use.
19. I have made some changes in my drug use, and I want some help to keep from going back
to the way I used before.
**Scoring automatically calculated online
If consumer is not available/already been discharged, skip questions 15-17:
15. What is your level of readiness for addressing your substance use?
Considering action sometime in the next few months (Contemplation) Seriously considering action this week (Preparation) 16. What is your level of confidence in your ability to make this change in your substance use?
Unsure of confidence level (Contemplation) 17. How convinced are you that you need to make change(s) in your substance use?
Unsure of level of conviction (Contemplation) Already taking action that expresses conviction that now is the time to address substance use (Action) Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 and 164. Consumer-identifyinginformation may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited.
Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
NC-TOPPS
ADATC Episode Completion Interview
**Use this form for backup only. Enter data into web-based system. (https://nctopps.ncdmh.net/adatc.htm)
If consumer is not available/already been discharged,
21. Are you taking any of the following medications for
skip questions 18-30:
alcohol/drug dependence? (mark all that apply)
18. Since admission, how well have you been doing in the following
areas of your life?
22. How would you describe your current mental health
symptoms?
19. To what extent did the services help.
23. Do you smoke cigarettes?
g. Manage your other mental health symptoms I smoke less than one pack a dayI do not smoke on a regular basis h. Deal with your history of trauma or abuse 24. Since admission, has your family, guardian, or
significant other been involved in any contact with
staff concerning any of the following?
k. Obtain outpatient treatment in your community l. Encourage your participation in self-help group(s) m. Improve relationships with your family and friends n. Improve your housing or living situation None of the above → (skip to 25) b. Since admission, how often has your family, guardian, or significant other been involved in any contact with 20. Do you have a current prescription for psychotropic medications?
b. How likely are you to continue taking the medications, as currently prescribed, following discharge? (mark only one) c. What are some of the reasons that you foresee not being able to take 25. If "None of the above" is answered on question 24, please
your medication(s) all or most of the time following discharge? specify a reason why no family member, guardian, or
significant other have been involved in person-centered
planning or treatment services: (mark all that apply)
Trouble in remembering to take medication(s)Too many medication(s) Consumer has no family, guardian, or significant other Do not feel need for medication(s)Forgot injection appointment No transportation to injection appointment Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 and 164. Consumer-identifyinginformation may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited.
Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
NC-TOPPS
ADATC Episode Completion Interview
**Use this form for backup only. Enter data into web-based system. (https://nctopps.ncdmh.net/adatc.htm)
26. Have you ever experienced domestic violence?
34. Females only: Have you given birth in the past year?
b. Did you have an opportunity to discuss this issue during your c. Would you like to speak with a staff person about this issue before your discharge? 27. Have you ever experienced childhood sexual abuse?
c. Did you receive prenatal care during pregnancy? b. Did you have an opportunity to discuss this issue during c. Would you like to speak with a staff person about this issue 28. During your treatment stay, did you try to hurt yourself or
f. How would you describe the baby's current health? cause yourself pain on purpose (such as cut, burned, or
bruised self)?
29. During your treatment stay, did you have thoughts of suicide?
Baby is not in birth mother's custody → (skip to 35) 30. During your treatment stay, did you have thoughts of killing
g. Is the baby receiving regular Well Baby/Health Check someone?
b. When the most recent thought(s) of killing someone occur? If consumer is not available/already been discharged,
skip questions 35-38:
35. What are the possible barriers that may prevent you from
attending outpatient services? (mark all that apply)
31. Other than for pregnancy, while in treatment, did you
receive off-campus medical care?
32. Females only: Have you ever been pregnant?
36. Were you offered HIV testing?
33. Females only: Are you currently pregnant?
b. How many weeks have you been pregnant? c. Have you been referred to prenatal care? 37. Have you been directly involved with any member of your
treatment team regarding discharge planning?
38. Have you been given a date and time to review your plan
prior to discharge?
Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 and 164. Consumer-identifyinginformation may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited.
Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
NC-TOPPS
ADATC Episode Completion Interview
**Use this form for backup only. Enter data into web-based system. (https://nctopps.ncdmh.net/adatc.htm)
39. COUNSELOR ASSESSMENT:
Identify the individual's current "Stage of Change" based on
clinical impression during this assessment as s/he is leaving
treatment.
Enter data into web-based system:
https://nctopps.ncdmh.net/adatc.htm
Do not mail this form
Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 and 164. Consumer-identifyinginformation may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to itsauthorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited.
Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
Attachment I:
DSM-IV TR Diagnostic Classifications
Childhood Disorders
Learning Disorders (315.00, 315.10, 315.20, 315.90) Autism and pervasive development (299.00, 299.10, 299.80) Attention deficit disorder (314.xx, 314.90) Communication disorders (307.00, 307.90, 315.31, 315.39) Childhood disorders-other (307.30, 309.21, 313.23, 313.89, 313.90) Mental Retardation (317, 318.00, 318.10, 318.20, 319) Substance-Related Disorders
Drug abuse (305.20, 305.30, 305.40, 305.50, 305.60, 305.70, 305.90) Drug dependence (304.00, 304.10, 304.20, 304.30, 304.40, 304.50, 304.60, 304.80, 304.90) Schizophrenia and Other Psychotic Disorders
Schizophrenia and other psychotic disorders (293.xx, 295.xx, 297.10, 297.30, 298.80, 298.90) Mood Disorders
Anxiety Disorders
Anxiety disorders (other than PTSD) (293.89, 300.00, 300.01, 300.02, 300.21, 300.22, 300.23, 300.29, 300.30, 308.30) Posttraumatic Stress Disorder (PTSD) (309.81) Adjustment Disorders
Personality, Impulse Control, and Identity Disorders
Personality disorders (301.00, 301.20, 301.22, 301.40, 301.50, 301.60, 301.70, 301.81, 301.82, 301.83, 301.90) Impulse control disorders (312.31, 312.32, 312.33, 312.34, 312.39) Sexual and gender identity disorders (302.xx, 306.51, 607.84, 608.89, 625.00, 625.80) Delerium, Dementia, & Other Cognitive Disorders
Delirium, dementia, and other cognitive disorders (290.xx, 290.10, 293.00, 294.10, 294.80, 294.90, 780.09) Disorders Due to Medical Condition and Medications
Mental disorders due to medical condition (306, 316) Medication induced disorders (332.10, 333.10, 333.70, 333.82, 333.90, 333.92, 333.99, 995.2) Somatoform, Eating, Sleeping & Factitious Disorders
Somatoform, eating, sleeping, and factitious disorders (300.xx, 300.11, 300.70, 300.81, 307.xx) Dissociative Disorders
Dissociative disorders (300.12, 300.13, 300.14, 300.15, 300.60) Other Disorders
Other mental disorders (Codes not listed above)

Source: https://nctopps.ncdmh.net/ADATC1011/NC-TOPPSADATCEpisodeCompletion10.pdf