• This should be from ED-Medicine, ED-Trauma, Consults, or Direct admission. You can find this in the ED notes or admission H&P.

• Please leave this blank for now.

• Put BAL number in ED or 24 hours after admission time. If BAL not collected or collected after 24 hours of admission, put -1 for the value.

• This is the patient sex at birth.

• Choices are Suicidal Ideation/Attempt, Psychosis, Mania, Other
• You can look at the discharge summary which usually has the admission H&P in it. If it is not there you can look at the ED notes.

• You can find this in the Social Work note under Personal Relationship History.

• This is usually in the Social Work note under Personal Relationship History. Please say yes if the patient's own children live with them. If some of the patient's children live with them, then put yes.

• This is only for patients who are transgender. If a patient is grossly psychotic and believes they were born as a different gender, then we can put fluid.

• Date of Admission is also in the patient header.

• This should be on the patient header.

• Use the diagnosis that is in the discharge diagnoses in the discharge summary.

• Use the diagnosis that is in the discharge diagnoses in the discharge summary.
• This include other bipolar disorder, bipolar I, and bipolar II.

• Use the diagnosis that is in the discharge diagnoses in the discharge summary.
• This is for borderline personality disorder.

• Use the diagnosis that is in the discharge diagnoses in the discharge summary.
• This includes historical diagnoses.

• Use the diagnosis that is in the discharge diagnoses in the discharge summary.
• This includes depressive and bipolar types.

• Use the diagnosis that is in the discharge diagnoses in the discharge summary.
• This includes schizophreniform, brief psychotic disorder.

• Use the diagnosis that is in the discharge diagnoses in the discharge summary.
• This includes alcohol and drug use disorder of any severity.
• Does not include tobacco use disorder.

• You can find this in the Social Work note under Income Sources.

• You can find this in the Social Work note under Education.

• You can find this in the Social Work note under Income Sources.

• You can find this information in the Social Work Note.
• Chronic homelessness is defined by HUD as homeless for 1 year or 4 times in the last 3 years.
• Otherwise put recent homelessness.
• If the patient stays at salvation army, haven for hope, or other shelter, then put chronically homeless or recent homelessness.
• If the patient was staying with someone and recently got kicked out put recent homeless. Even if the patient eventually returns to live with that person on discharge, put recent homeless if the patient was kicked out before admission.

• You can find insurance in the patient info tab.
• If the patient has managed care plan for Medicaid select Medicaid. The following are Managed Care Organizations for Medicaid.
  • STAR: Amerigroup, Community First, Community Health Choice, Cook Children's, Driscoll, El Paso First Premier, First Care, Molina, Parkland Community Health Plan, Superior HealthPlan, Texas Children Health Plan, Unicare, United
  • STAR+ PLUS: Amerigroup, Bravo, Evercare, Molina, Superior HealthPlan
  • NorthSTAR: Value Options
  • STAR Health: Superior Health Plan
  • Texas Medicaid Wellness Program: McKes
  • Managed medicaid options in Texas include STAR, STAR+PLUS, Amerigroup, Molina
• If the patient has a location specific insurance that does not work in San Antonio, then put no insurance. For example, MediCal only works in California.

• If the patient has ever been in jail or prison. You can find this sometimes in the chart with notes labelled DHCS.
• More reliably, this information is in the social work note. You should always ask about a history of legal problems for your patient as it can be very revealing.

• Name as listed. If the patient is unknown, then when we find the name put it in. If the name is misspelled, put the name that the chart will eventually reflect. If it's not clear if the name will be changed, use the name that is in the chart right now.

• Yes, No, Ordered, but not completed, Not Applicable, Not Ordered.
• If the LCDC mentions they were unable to get information or the patient did not want to talk to them, select this as No.
• If the LCDC mentions was able to get information, select this as Yes.
• If the patient has a substance use disorder, but LCDC consult was not ordered, then put Not Ordered.
• If the patient has an LCDC order, but it was not done then put Ordered, but not completed.
• If the patient has no substance use disorder, then put not applicable.

• If the patient states they are married, put married. If this is clearly a delusion then put not married.
• If the patient is married, but no longer living with their spouse put Separated.
• If the patient has a long term partner, please put single. If the patient has no partner, then put single as well.
• Widowed and divorced if the patient is divorced and has not remarried.
• If the patient states they are married and you get collateral and the person states they are not married, put disagreement. If the patient states that she is not married and the person states they are married, also put disagreement.
• You can find this information in the Social Work Note.

• If at anytime the patient refused a medication for any reason during this hospital stay.

\begin{figure} \includegraphics{ptinfodemographics.png} \caption{MRN on Patient Header} \label{fig3:headerMRN} \end{figure}

• MRN is easily found in the patient header\ref{fig3:headerMRN}.

• If you go to orders section, you can look at all orders including discontinued orders. However given the current covid protocol all patients are no roommate.

• On the discharge summary it should state where the patient needs to followup.
• If you do not know, please ask the social worker or discharge expediter, as an integral part of inpatient care is ensuring follow up.

• If the patient arrived with a physical trauma of a gunshot wound, stabbing, fracture, or required sutures, then select the relevant section on the combo box.
• If the patient has multiple of these, put the most acute one. Also let Dr. Dhawan know.

• Pregnancy test from the ED
• If not collected, put Not pregnant.

• If the patient has had a psychiatric hospitalization in the last month then put Yes otherwise put No.
• Do not include ED visits or hosptializations for non-psychiatric reasons.

• This should be in the Psychiatric History in the H&P. If the patient say >10 hospitalizations, put 10.
• If hospitalizations are unknown, then put -1.
• If you can confirm more hospitalizations in the chart, put the number of hospitalizations you confirmed in the chart.
• If in the notes you find that the patient says different numbers of hospitalizations, please put the number of hospitalizations the patient states, unless you can confirm with our own admissions, DHCS showing admissions to SASH, or from medical record from other institutions.
• Do not include stays at crisis centers or emergency room visits without psychiatric hospitalizations.

• This can be found in the Patient demographics section.

\begin{figure} \centering \includegraphics[scale=0.3]{headerptinfo.png} \caption{Patient Header with arrow to Patient Info Tab.} \label{fig1:patientinfotab} \end{figure}

• On the patient's screen there are multiple tabs below the header, for example, documents, results. Go to Patient Info tab\ref{fig1:patientinfotab}. On the left there is Patient Demographics.

\begin{figure} \includegraphics{ptinfodemographics.png} \caption{Patient Demographics in Patient Info Tab.} \label{fig2:demographicsarrow} \end{figure}

• Double click on the Patient Demographics\ref{fig2:demographicsarrow} as above and a window will pop up. In the bottom of the window there is a section for race and ethnicity which you can enter into the database.

• This includes the emergency room.
• You can find this by looking at the orders.

• This is on the ED notes. If the ED notes state ambulatory, put self presented.

• This is for self injurious behavior, e.g., cutting that isn't to end one's life. It is a symptom of borderline personality disorder.
• Put Yes for SIB if patient has any history of this even if not recent.
• This information should be in the admission h&p. If it is not there put no SIB.
• You should ask this of all your patients.

• If the patient has a history of a suicide attempt and states that it was with intent to end their life select this one.
• You should ask all your patients about intentionality and lethality of their suicide attempts.
• You can find this in the past psych history in the discharge summary, the H&P, and sometimes in the Columbia Suicide Rating Scale.

• The time of admission should be from the Patient List tab\ref{fig4:admittime}.

\begin{figure} \centering \includegraphics[scale=0.4,trim={0 0 8cm 0},clip]{ptlistadmittime.png} \caption{Patient Admit Time} \label{fig4:admittime} \end{figure}

• If the patient is transferred, then use the time the transfer or admit order was entered. You can find this on the orders tab.

• This UDS is only on admission or 24 hours after admission. If the UDS is after that, put UDS not collected. If two UDS's were done just include the UDS during admission.
• Time that UDS was collected is in the orders tab.
• This should be in the admission labs. If not present then select UDS not collected.
• You can also find the UDS in the admission H&P and the discharge H&P.

• This UDS is only on admission or 24 hours after admission. If the UDS is after that, put UDS not collected. If two UDS's were done just include the UDS during admission.
• Time that UDS was collected is in the orders tab.
• This should be in the admission labs. If not present then select UDS not collected.
• You can also find the UDS in the admission H&P and the discharge H&P.

• This UDS is only on admission or 24 hours after admission. If the UDS is after that, put UDS not collected. If two UDS's were done just include the UDS during admission.
• Time that UDS was collected is in the orders tab.
• This should be in the admission labs. If not present then select UDS not collected.
• You can also find the UDS in the admission H&P and the discharge H&P.

• This UDS is only on admission or 24 hours after admission. If the UDS is after that, put UDS not collected. If two UDS's were done just include the UDS during admission.
• Time that UDS was collected is in the orders tab.
• This should be in the admission labs. If not present then select UDS not collected.
• You can also find the UDS in the admission H&P and the discharge H&P.

• Put UDS Not Collected if UDS was not done in the ED or 24 hours after admission. If UDS collected after 24 hours, please put UDS not collected.
• Time that UDS was collected is in the orders tab.

• This UDS is only on admission or 24 hours after admission. If the UDS is after that, put UDS not collected. If two UDS's were done just include the UDS during admission.
• Time that UDS was collected is in the orders tab.
• This should be in the admission labs. If not present then select UDS not collected.
• You can also find the UDS in the admission H&P and the discharge H&P.