County of Sonoma Department of Health Services Behavioral Health Division
CLIENT EPISODE DISCHARGE LEGEND
Legend instructions: Use the numeric selection for the appropriate category when applicable. Each field must be completed.
Client Discharge form may not be submitted with blank fields.
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1. Type of Discharge
Client Died
Client Dischrged/Program Unilateral Decision
Client Incarcerated
Client Moved Out of Service Area
Client Withdrew:AWOL,AMA/No Improvement
Client Withdrew:AWOL,AMA/Treat Partially
Completed
Discharge/Administrative Reasons
Lost - No Follow Up
Mutual Agreement/Treatment Goals Reached
Mutual Agreemnt/Treat Goals Not Reached
Mutual Agreemnt/Treat Goals Partially
Reached
Other
2. Birth Name (Last)
Enter Last name only
3. Mothers First Name
If not known enter Unknown
4. Alias
Enter Last Name, First Name
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7. Primary Language
American Sign Language (ASL)
Arabic
Armenian
Cambodian
Cantonese
English
Farsi
French
Hebrew
Hmong
Ilacano
Italian
Japanese
Korean
Lao
Mandarin
Mien
Other Chinese Languages
Samoan
Spanish
Tagalog
Thai
Turkish
Unknown/Not Reported
Vietnamese
8. Ethnic Origin
Cuban
Mexican/Mexican American
Not Hispanic
Other Hispanic/Latino
Puerto Rican
Unknown
9. Place of Birth (County Code,
State, Country)
Ex. 49 CA US
5. Birth Name (First)
Only enter first name
6. Marital Status
Divorced/Dissolved/Annulled
Never Married
Now Married/Remarried/Living together
Separated
Unknown
Widowed
(cont’d Primary Language)
Other Non-English
Other Sign Language
Polish
Portuguese
Russian
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10. Client Race
Alaska Native
American Indian
Asian Native
Black/African-American
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Korean
Laotian
Other Asian
Other Race
Samoan
Vietnamese
White
11. Education
01 Years
02 Years
03 Years
04 Years
05 Years
06 Years
07 Years
08 Years
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MHS 150 Legend (06-15)
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(cont’d Education)
09 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 + Years
1 Yr Vocational /Technical
2 Yrs Vocational/Technical
1 Yr Special Education
2 Yrs Or More Special Education
1 Yr Preschool
2 Yrs Or More Preschool
None
Unknown
12. Smoker
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Current Every Day Smoker
Current Some Day Smoker
Current Status Unknown
Former Smoker
Heavy Tobacco Smoker
Light Tobacco Smoker
Never Smoked
Smoker
Unknown If Ever Smoked
13. Other Race(s)
Alaskan Native
American Indian
Asian Native
Black/African-American
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Korean
Laotian
Other Asian
Other Race
Samoan
Vietnamese
White
County of Sonoma Department of Health Services Behavioral Health Division
CLIENT EPISODE DISCHARGE LEGEND
Legend instructions: Use the numeric selection for the appropriate category when applicable. Each field must be completed.
Client Discharge form may not be submitted with blank fields.
14. Employment Status
16. Discharge Legal Class
20. Axis IV (Y) Yes (N) No
Is there any Psychosocial and Environmental
problems that may affect the diagnosis treatment and
prognosis of Mental Disorder?
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Compet job market 20-35 hrs a week
Compet job market 35 hrs or more a week
Compet job market less thn 20 hrs a week
Full-time homemaking responsibility
Job Training, Full-Time
Not in the labor force
Part-time school/job training
Rehabilitative work, 20 to 35 hrs a week
Rehabilitative work, 35 hrs or more a
week
Rehabilitative work, less 20 hrs a week
Resident/Inmate
Retired
School, full-time
Unemployed, actively seeking work
Unemployed, not actively seeking work
Unknown
Volunteer Work
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Additional 14 Day Hold
Additional 30 Day Hold
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11-20
Additional 180 Day Hold
21-30
Other involuntary civil status
31-40
Charges and/or convictions pending
Determination of competency to stand trial
Found "not guilty by reason of insanity" or
"guilty but insane"
Determination of sexual psychopathy and
related legal categories
Transferred from correctional facilities
Other involuntary criminal status
Unknown/Not Reported
If Sonoma County did not contract with
you to complete Assessments, leave boxes
17 through 25 blank.
41-50
51-60
61-70
71-80
81-90
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92100
41 - 50 Serious Symptoms Or Impairment
51 - 60 Moderate Symptoms Or Difficulty In
Functioning
61 - 70 Mild Symptoms Or Some Difficulty In
Functioning
71 - 80 Slight Impairment In Functioning
81 - 90 Good Functioning In All Areas
91 - 99 Superior Functioning - No Symptoms Present
92 - 100 Superior Functioning - No Symptoms Present
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Yes
No
Unknown
17. Axis I Diagnosis (P) Primary or (S)
Secondary
23. Substance Abuse/Dependence
18. Axis II Diagnosis (P) Primary (S)
Secondary
19. Axis III
If not known enter Unknown
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MHS 150 Legend (06-15)
0
21. Axis V Current GAF Rating (Enter exact numeral
rating on the Episode Discharge MHS 150)
0 Inadequate Information
1 - 10 Persistent Danger Or Inability To Maintain
Hygiene
11 - 20 Some Danger Of Hurting Self Or Others Or
Gross or Impairment in Communications
21 - 30 Delusions Or Hallucinations Or Serious
Impairment
31 - 40 Impairment In Reality Testing Or
Communication
22. Trauma (Y) Yes (N) No
***
15. Patient Status Code
Still a patient or expected to return
Discharged to home, self-care, foster
care, shelter care
Discharged/transferred to
Residential/Board and Care (not locked,
supervised living, no treatment)
Discharged/transferred to Community
Residential Treatment (not locked or
custodial)
Discharged/transferred to Community
Treatment Facility (locked, no nursing
care)
Discharged/transferred to Skilled Nursing
Facility/Intermediate Care Facility
(unlocked or locked)
Discharged/transferred to Acute Care
Hospital or Psychiatric Health Facility
(PHF)
Discharged/transferred to State Hospital
Discharged/transferred to Jail
Unplanned discharge
Expired
Other
Unknown/Not Reported
Voluntary
72 Hour Evaluation and Treatment for
Adults
72 Hour Evaluation and Treatment for
Children
14 Day Intensive Treatment
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Yes
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No
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Unknown/Not Reported
County of Sonoma Department of Health Services Behavioral Health Division
CLIENT EPISODE DISCHARGE LEGEND
Legend instructions: Use the numeric selection for the appropriate category when applicable. Each field must be completed.
Client Discharge form may not be submitted with blank fields.
24. Diagnosing Practitioner
Enter Practitioner staff number assigned by Sonoma County
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25. General Medical Condition Summary Code
Allergies
Anemia
Arterial Sclerotic Disease
Arthritis
Asthma
Birth Defects
Blind / Visually Impaired
Cancer
Carpal Tunnel Syndrome
Chronic Pain
Cirrhosis
Cystic Fibrosis
Deaf / Hearing Impaired
Diabetes
Digestive Disorders (Reflux, Irritable Bowel Syndrome)
Ear Infections
Epilepsy / Seizures
Heart Disease
Hepatitis
Hypercholesterolemia
Hyperlipidemia
Hypertension
Hyperthyroid
Infertility
Migraines
Multiple Sclerosis
Muscular Dystrophy
No General Medical Condition
Obesity
Osteoporosis
Other
Parkinson's Disease
Physical Disability
Psoriasis
Sexually Transmitted Disease (STD)
Stroke
Tinnitus
Ulcers
Unknown / Not Reported General Medical Condition
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MHS 150 Legend (06-15)