ID

11670

Description

ODM form derived from [DAST Entlassung PSYCH UKM]. Used as a routine documentation by the University Hospital Muenster, Germany.

Keywords

  1. 7/25/15 7/25/15 -
  2. 7/26/15 7/26/15 -
  3. 11/7/17 11/7/17 -
Copyright Holder

It was copyrighted in 1982 by Harvey Skinner, PhD and the Centre for Addiction and Mental Health, Toronto, Canada. It may be reproduced for non-commercial use (clinical, research, training purposes) as long as credit is given to author Harvey A. Skinner,

Uploaded on

July 26, 2015

DOI

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License

Creative Commons BY-NC-ND 3.0

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DAST basic documentation - discharge

DAST basic documentation - discharge

Patient demographics
Description

Patient demographics

Patient name
Description

Patient Name

Data type

text

Alias
UMLS CUI-1
C1299487
Date of admission
Description

Date of admission

Data type

date

Alias
UMLS CUI-1
C1302393
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI-1
C0421451
Registration date
Description

Registration date

Data type

date

Alias
UMLS CUI-1
C2985881
Attending physician
Description

Attending physician

Data type

text

Alias
UMLS CUI-1
C1320929
Physical therapy
Description

Physical therapy

Alias
UMLS CUI-1
C0949766
Multiple answers are possible
Description

Multiple answers are possible

Data type

integer

Alias
UMLS CUI-1
C0949766
Psychotherapy session
Description

Psychotherapy session

Data type

text

Alias
UMLS CUI-1
C0033968
Psychotherapy
Description

Psychotherapy

Number of psychotherapy sessions
Description

Number of psychotherapy sessions

Data type

integer

Alias
UMLS CUI-1
C0033968
Psychotherapeutic approach
Description

Psychotherapeutic approach

Psychotherapy Therapeutic Technique
Description

Psychotherapy Therapeutic Technique

Data type

integer

Alias
UMLS CUI-1
C0237915
Further therapeutic treatment
Description

Further therapeutic treatment

Only if manually-oriented applied, multiple answer are possible
Description

Only if manually-oriented applied, multiple answer are possible

Data type

integer

Discharge Medications - Somatic indication
Description

Discharge Medications - Somatic indication

Please indicate medication and daily doses in mg or ml
Description

Please indicate medication and daily doses in mg or ml

Data type

integer

Alias
UMLS CUI-1
C1553894
Discharge Medications - psychiatric indication
Description

Discharge Medications - psychiatric indication

Please indicate medication and daily doses in mg or ml
Description

Please indicate medication and daily doses in mg or ml

Data type

integer

Alias
UMLS CUI-1
C1553894
ECG
Description

ECG

QTc interval in sec
Description

QTc interval in sec

Data type

integer

Measurement units
  • sec
sec
Patient weight
Description

Patient weight

Weight in kg
Description

Weight in kg

Data type

integer

Alias
UMLS CUI-1
C0005910
Problems during psychotherapy
Description

Problems during psychotherapy

Check all that apply
Description

Check all that apply

Data type

integer

Alias
UMLS CUI-1
C0033968
UMLS CUI-2
C0033213
Further therapeutic treatment
Description

Further therapeutic treatment

Follow-up treatment
Description

Follow-up treatment

Data type

integer

Alias
UMLS CUI-1
C0422322
Follow-up care
Description

Follow-up care

Check all that apply
Description

Check all that apply

Data type

integer

Alias
UMLS CUI-1
C0422322
Out-patient follow-up care / follow-up treatment
Description

Out-patient follow-up care / follow-up treatment

None
Description

None

Data type

text

General practitioner
Description

General practitioner

Data type

integer

Alias
UMLS CUI-1
C0017319
Psychiatrist
Description

Psychiatrist

Data type

integer

Alias
UMLS CUI-1
C0033872
Psychologist
Description

Psychologist

Data type

text

Alias
UMLS CUI-1
C0033908
Polyclinic
Description

Polyclinic

Data type

text

Alias
UMLS CUI-1
C1221423
Other psychiatric ambulance
Description

Other psychiatric ambulance

Data type

text

mental health administrator
Description

mental health administrator

Data type

text

Alias
UMLS CUI-1
C0009475
Councelling centre / advice centre
Description

Councelling centre / advice centre

Data type

text

Alias
UMLS CUI-1
C0542296
Support-group
Description

Support-group

Data type

text

Nursing service
Description

Nursing service

Data type

text

Alias
UMLS CUI-1
C0028697
Other
Description

Other

Data type

integer

Unknown
Description

Unknown

Data type

integer

Psychiatric discharge diagnosis
Description

Psychiatric discharge diagnosis

ICD-10
Description

ICD-10

Data type

text

Alias
UMLS CUI-1
C0870733
UMLS CUI-2
C1555319
DSM-IV
Description

DSM-IV

Data type

text

Alias
UMLS CUI-1
C0220952
UMLS CUI-2
C1555319
Somatic discharge diagnosis
Description

Somatic discharge diagnosis

Alias
UMLS CUI-1
C1555319
Clinical Global Impression (Degrees of severity)
Description

Clinical Global Impression (Degrees of severity)

Severity Score
Description

Severity Score

Data type

integer

Clinical Global Impression Scale of Change (CGI-C)
Description

Clinical Global Impression Scale of Change (CGI-C)

Overall change of status
Description

Overall change of status

Data type

integer

Alias
UMLS CUI-1
C3639708
Efficacy index (desired pharmacological drug effects)
Description

Rate this item on the basis of drug effect only. Select the terms which best describe the degrees of therapeutic effect and side effects and record the number in the box where the two items intersect. EXAMPLE: Therapeutic effect is rated as ‘Moderate’ and side effects are judged ‘Do not significantly interfere with patient’s functioning’.

Data type

integer

Alias
UMLS CUI-1
C3639889
Side effects
Description

Side effects

Data type

integer

Alias
UMLS CUI-1
C0041755

Similar models

DAST basic documentation - discharge

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient demographics
Patient Name
Item
Patient name
text
C1299487 (UMLS CUI-1)
Date of admission
Item
Date of admission
date
C1302393 (UMLS CUI-1)
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI-1)
Registration date
Item
Registration date
date
C2985881 (UMLS CUI-1)
Attending physician
Item
Attending physician
text
C1320929 (UMLS CUI-1)
Item Group
Physical therapy
C0949766 (UMLS CUI-1)
Item
Multiple answers are possible
integer
C0949766 (UMLS CUI-1)
Code List
Multiple answers are possible
CL Item
None (1)
C0549184 (UMLS CUI-1)
CL Item
Pharmacotherapy  (2)
C0013216 (UMLS CUI-1)
CL Item
Electroconvulsive therapy (3)
C0013806 (UMLS CUI-1)
CL Item
Sleep deprivation (4)
C0037316 (UMLS CUI-1)
CL Item
Light therapy (5)
C0031765 (UMLS CUI-1)
CL Item
Other (6)
Psychotherapy session
Item
Psychotherapy session
text
C0033968 (UMLS CUI-1)
Item Group
Psychotherapy
Item
Number of psychotherapy sessions
integer
C0033968 (UMLS CUI-1)
Code List
Number of psychotherapy sessions
CL Item
None (1)
C0549184 (UMLS CUI-1)
CL Item
Individual psychotherapy <30 mins (2)
C0204525 (UMLS CUI-1)
C3842955 (UMLS CUI-2)
CL Item
Individual psychotherapy >30 mins (3)
C0204525 (UMLS CUI-1)
CL Item
Group psychotherapy (4)
C0033971 (UMLS CUI-1)
Item Group
Psychotherapeutic approach
Item
Psychotherapy Therapeutic Technique
integer
C0237915 (UMLS CUI-1)
Code List
Psychotherapy Therapeutic Technique
CL Item
No Psychotherapy  (1)
C0549184 (UMLS CUI-1)
C0033968 (UMLS CUI-2)
CL Item
Supportive Psychotherapy  (2)
C0221295 (UMLS CUI-1)
CL Item
Depth psychology oriented Psychotherapy (3)
C0870405 (UMLS CUI-1)
CL Item
Cognitive behavioral therapy (4)
C0009244 (UMLS CUI-1)
CL Item
Person-centered therapy (Rogers) (5)
C0237843 (UMLS CUI-1)
CL Item
Interpersonal Psychotherapy  (6)
C0871787 (UMLS CUI-1)
CL Item
Psychodynamic interactional Psychotherapy (7)
C0599237 (UMLS CUI-1)
CL Item
Group Therapy (8)
C0033971 (UMLS CUI-1)
CL Item
Other (9)
CL Item
Unknown (10)
Item Group
Further therapeutic treatment
Item
Only if manually-oriented applied, multiple answer are possible
integer
Code List
Only if manually-oriented applied, multiple answer are possible
CL Item
None (1)
CL Item
Psychoeducation (Group/Individual) (2)
C0871175 (UMLS CUI-1)
CL Item
Cognitive training (Group/Individual) (3)
C1868940 (UMLS CUI-1)
CL Item
Relaxation Therapy (Group/Individual) (4)
C0282333 (UMLS CUI-1)
CL Item
Social competence education (Group) (5)
C0815250 (UMLS CUI-1)
CL Item
Symptom management training (Group/Individual) (6)
C1536570 (UMLS CUI-1)
CL Item
Behaviour therapy relative groups (7)
C0004933 (UMLS CUI-1)
CL Item
Other/ Remarks (8)
C0205394 (UMLS CUI-1)
Item Group
Discharge Medications - Somatic indication
Please indicate medication and daily doses in mg or ml
Item
Please indicate medication and daily doses in mg or ml
integer
C1553894 (UMLS CUI-1)
Item Group
Discharge Medications - psychiatric indication
Please indicate medication and daily doses in mg or ml
Item
Please indicate medication and daily doses in mg or ml
integer
C1553894 (UMLS CUI-1)
Item Group
ECG
QTc interval in sec
Item
QTc interval in sec
integer
Item Group
Patient weight
Weight in kg
Item
Weight in kg
integer
C0005910 (UMLS CUI-1)
Item Group
Problems during psychotherapy
Item
Check all that apply
integer
C0033968 (UMLS CUI-1)
C0033213 (UMLS CUI-2)
Code List
Check all that apply
CL Item
None (1)
CL Item
Lack of motivation to change (2)
CL Item
deterioration of symptoms  (3)
CL Item
Termination (via Therapist) based on other reasons (4)
CL Item
Other (please indicate) (5)
Item Group
Further therapeutic treatment
Item
Follow-up treatment
integer
C0422322 (UMLS CUI-1)
Code List
Follow-up treatment
CL Item
Daytime clinic (1)
CL Item
Non-stationary treatment (2)
CL Item
Other psychiatric clinic (3)
CL Item
Stationary facility for addicts (4)
CL Item
Psychotherapeutical/ somatic clinic (5)
CL Item
Other (6)
CL Item
Unknown (7)
Item Group
Follow-up care
Item
Check all that apply
integer
C0422322 (UMLS CUI-1)
Code List
Check all that apply
CL Item
None (1)
CL Item
occupational rehabilitation (2)
CL Item
assisted living (3)
CL Item
Forensic psychiatry (4)
CL Item
day care (5)
CL Item
Other (6)
CL Item
Unknown (7)
Item Group
Out-patient follow-up care / follow-up treatment
None
Item
None
text
Item
General practitioner
integer
C0017319 (UMLS CUI-1)
Code List
General practitioner
CL Item
No (1)
CL Item
Yes, GP contacted (2)
CL Item
Yes, GP not contacted (3)
Item
Psychiatrist
integer
C0033872 (UMLS CUI-1)
Code List
Psychiatrist
CL Item
No (1)
CL Item
Yes, Psychiatrist contacted (2)
CL Item
Yes, Psychiatrist not contacted (3)
Item
Psychologist
text
C0033908 (UMLS CUI-1)
Code List
Psychologist
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
Item
Polyclinic
text
C1221423 (UMLS CUI-1)
Code List
Polyclinic
CL Item
No (1)
CL Item
Yes, Polyclinic contacted (2)
CL Item
Yes, Polyclinic not contacted (3)
Item
Other psychiatric ambulance
text
Code List
Other psychiatric ambulance
CL Item
No (1)
CL Item
Yes, Psychologist contacted (2)
CL Item
Yes, Psychologist not contacted (3)
Item
mental health administrator
text
C0009475 (UMLS CUI-1)
Code List
mental health administrator
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Item
Councelling centre / advice centre
text
C0542296 (UMLS CUI-1)
Code List
Councelling centre / advice centre
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Item
Support-group
text
Code List
Support-group
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Item
Nursing service
text
C0028697 (UMLS CUI-1)
Code List
Nursing service
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Item
Other
integer
Code List
Other
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Item
Unknown
integer
Code List
Unknown
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Item Group
Psychiatric discharge diagnosis
ICD-10
Item
ICD-10
text
C0870733 (UMLS CUI-1)
C1555319 (UMLS CUI-2)
DSM-IV
Item
DSM-IV
text
C0220952 (UMLS CUI-1)
C1555319 (UMLS CUI-2)
Item Group
Somatic discharge diagnosis
C1555319 (UMLS CUI-1)
Item Group
Clinical Global Impression (Degrees of severity)
Item
Severity Score
integer
Code List
Severity Score
CL Item
cannot be assessed (0)
CL Item
normal, not at all ill (1)
CL Item
borderline mentally ill (2)
CL Item
mildly ill (3)
CL Item
moderately ill (4)
CL Item
markedly ill (5)
CL Item
severely ill (6)
CL Item
extremely ill (7)
Item Group
Clinical Global Impression Scale of Change (CGI-C)
Item
Overall change of status
integer
C3639708 (UMLS CUI-1)
Code List
Overall change of status
CL Item
normal, not at all ill (1)
CL Item
borderline mentally ill (2)
CL Item
mildly ill (3)
CL Item
moderately ill (4)
CL Item
markedly ill (5)
CL Item
severely ill (6)
CL Item
extremely ill (7)
CL Item
can not be evaluated (0)
Item
Efficacy index (desired pharmacological drug effects)
integer
C3639889 (UMLS CUI-1)
Code List
Efficacy index (desired pharmacological drug effects)
CL Item
Not assessed (0)
CL Item
Vast improvement. Complete or nearly complete remission of all symptoms (1)
CL Item
Decided improvement. Partial remission of symptoms (2)
CL Item
Slight improvement which doesn’t alter status of care of patients (3)
CL Item
Unchanged or worse (4)
Item
Side effects
integer
C0041755 (UMLS CUI-1)
Code List
Side effects
CL Item
can not be evaluated (0)
CL Item
None (1)
CL Item
Do not significantly interfere with patient’s functioning  (2)
CL Item
significantly interfere with patient’s functioning  (3)
CL Item
Outweighs therapeutic effect (4)

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