***DRAFT***
September 3, 1998
Encounter
Data Elements
VI. ENCOUNTER DATA ELEMENTS [Data reported at every encounter; phone, face-to-face; collateral.]:
Item |
FN-11 |
Source |
Other |
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|
# |
Data Element |
Document |
Name |
Definition |
Workgroup Comments |
1 |
Client Unique Identifier | EE #64, 81 FN-10 p.149 |
Personal Unique Identifier | The unique client identifier that enables the data from multiple files/records to be reliably associated with a particular individual. | To get client specific information or to share and link data. |
2 |
Service Transaction Identifier | EE #27 CA |
Unique service record identifier, computer generated | For waiting record trail | |
3 |
Organization Identifier | EE #34 FN-10 p.149 |
Federal ID Number or National Provider ID Number | Linkage to other data | |
4 |
Provider Identification | EE #35 FN-10 p.132 |
Federal ID Number or National Provider ID Number | Linkage to other data | |
Item |
FN-11 |
Source |
Other |
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|
# |
Data Element |
Document |
Name |
Definition |
Workgroup Comments |
5 |
Type of Service | EE #28 FN-10 p.61 CC p.26 |
Program Element Activity; Type of Event; Program Element Identifier | Classification of services to be defined: Some
examples include: 24 Hour Services: Hospital Inpatient Hospital Administrative Day Psychiatric Health Facility Skilled Nursing Facility IMD Basic (no patch) or With Patch Residential, Other Adult Crisis Residential Jail Inpatient Respite Care Outpatient Services: (Outpatient Visits) Alcohol/Drug Abuse Case Management (Contracts) Collateral Individual (Counseling, Health Therapy) Medication Support Psychosocial Rehabilitation Ambulatory (Services-ambulatory) Screening and Evaluation, assessment (CC p.21) Supportive Services (CC p.21) Prevention (CC p.21) Consultation and Education (CC p.21) Children’s Special Service (EE #31) Peer Counseling Self Help Day Services: Vocational Services Socialization Day Treatment Day Rehabilitation Club House Crisis Services: Crisis Stabilization – Emergency Room (Psych. ER Visits Resulting in Inpatient Admission) Crisis Stabilization Crisis Outpatient |
Issues of Setting v. Service need to be addressed Insure innovative services are added as appropriate |
Item |
FN-11 |
Source |
Other |
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# |
Data Element |
Document |
Name |
Definition |
Workgroup Comments |
|
6 |
Service Begin Date | EE #23 FN-10 p.149 |
Date Service Begins; Date of most recent admission to organization | The beginning date the client began each service, consultation, or procedure covered by a bill. (mm/dd/yyyy) (Inpatient and residential treatment services) | Length of stay analysis, appropriateness, utilization management | |
7 |
Service Ending Date | EE #24 FN-10 p.149 |
Date Service Ends; Date of discontinuation/discharge/death | The ending date for each service, consultation, or procedure covered by a bill. (mm/dd/yyyy) (Inpatient and residential treatment services) | ||
8 |
Date of Service | EE #22 FN-10 p.60 |
Date of Event | The date on which the mental health service was provided to the covered person. (mm/dd/yyyy) (outpatient services) | utilization management, cost analyses | |
9 |
Location of Service | EE #6, 9, 26 FN-10 p.64 CC p.26 |
Service location; Emergency Room Visits; On-site Intervention; Location of Event | The location where the services were rendered for
Mental Health Services. Premises of the program element or the mental health organization Other clinical setting Jail Nursing Home Inpatient Hospital School Patient’s place of residence Street or other public place Phone Other (detail should be maintained) |
Outreach indicator, resource allocation | |
10 |
Unit of Service | EE #29 |
The number of identical services or supplies rendered by type of service or procedure code to or for the client. | Utilization Management, cost analyses | ||
11 |
Unit of Time | EE #10 FN-10 p.63 |
Length of Event; Event Duration | Amount of time staff member was involved in select Day Services and all Outpatient Services | Utilization management, cost analyses. Must be able to include "unitless events," e.g. psychiatric assessment, medical clinic visit | |
Item |
FN-11 |
Source |
Other |
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# |
Data Element |
Document |
Name |
Definition |
Workgroup Comments |
|
12 |
Principal Mental Health Diagnosis for which treatment is provided (see note on III, no. 18) | EE #40, 42, 46, 47 FN-10 p.151 |
First Behavioral Health Diagnosis; Diagnosis Chiefly Responsible for Services Provided; Physician’s Tentative Diagnosis (ambulatory); Primary Diagnosis (inpatient); Diagnosis-admission, most current or updated, and discharge | The principal mental health diagnosis from DSM-IV or ICD-9CM used to indicate the primary reason for treatment. | Utilization management | |
13 |
Second Mental Health Diagnosis | EE #43 |
Second Behavioral Health Diagnosis; Other Diagnosis (inpatient) | The secondary mental health diagnosis from DSM-IV or ICD-9CM | Utilization management | |
14 |
Disenrollment Disposition | EE #54 (?) FN-10 p.46 CC p.23 |
Discharge Disposition; Discontinuation Status | Transferred Administratively discontinued (no contact with organization for 90 days) Client died Client terminated services against advice Client lost to contact Discharged –treatment completed; no referral Discharged –additional services advised; no referral Discharged –Additional services advised; referral made Not applicable |
Case management | |
15 |
Disposition of Encounter | Workgroup |
Continue Treatment; Referral out | Case Management | ||
16 |
Presence of other staff members | FN-10 p.63 CC p.26 |
Staff member (s) participating | No other staff
members involved in the event Other staff involved in the event, with identifiers for each, including a special flag identifying the staff who is regarded as primarily responsible and accountable for the event, e.g., primary therapist, team leader, etc. |
Lost accounting | |