Mental Health Information System (MHIS) Manual

Page Posted: 06/02/14

Page Reviewed: 8/22/2022

Page Updated: 8/12/2019

5.1.6. Dialectical Behavioral Therapy IOP (DBT)

DBT Variable fields outlined in the following section are required reporting when client record includes program treatment code [11] DBT.

Values are not collected for records where program treatment code [11] DBT is not indicated.

VARIABLE NAME: DBT – Age Client Received First Mental Health Service

DESCRIPTION: Age client first received any type of mental health service.

VALID ENTRIES:

01-99

GUIDELINES:

· If mental health records are not available and client does not recall exact age when they first received mental health service or they are unable to distinguish a mental health service from other services (i.e. social services) enter an estimate of age at first mental health service.

FIELD NUMBER: D1

FIELD LENGTH: 2

FIELD TYPE: Numeric

FORMAT: XX

VARIABLE NAME: DBT – Number of Years Client Received DBT Services

DESCRIPTION: Total number of years where client received any treatment that the client refers to as DBT treatment.

VALID ENTRIES:

[1] One year or less

[2] 1+ up to 5 years

[3] 5+ up to10 years

[4] 10+ years

GUIDELINES:

· Account for the total time that the client received DBT in any setting (day treatment, residential, etc.).

FIELD NUMBER: D2

FIELD LENGTH: 1

FIELD TYPE: Text

FORMAT: X

VARIABLE NAME: DBT – Borderline Symptom List (BSL) Total Score

DESCRIPTION: Enter total score of 23-item client self-report of symptoms.

VALID ENTRIES:

0-92

[97] Not required

[99] Unknown

GUIDELINES:

· The BSL-23 is a table with a set of difficulties and problems that may describe the client within the last week. To arrive at the total BSL-23 score add each column of numbers, and then add totals of each column for the total score.

FIELD NUMBER: D3

FIELD LENGTH: 2

FIELD TYPE: Numeric

FORMAT: XX

VARIABLE NAME: DBT – Borderline Symptom List (BSL) – Supplemental Total Score

DESCRIPTION: Enter total score of 11-item client self-report of behaviors.

VALID ENTRIES:

0-44

[97] Not required

[99] Unknown

GUIDELINES:

· The BSL-Supplement: Items for Assessing Behavior is a table with a set of behaviors that the client may have engaged in within the last week. To arrive at the total BSL- Supplement score add each column of numbers, and then add totals of each column for the total score.

FIELD NUMBER: D4

FIELD LENGTH: 2

FIELD TYPE: Numeric

FORMAT: XX

VARIABLE NAME: DBT – Medical Admission For Self-Harm Injuries – Days: Preceding 6 Months

DESCRIPTION: Number of days the client was on an inpatient medical unit for self-harm injuries.

VALID ENTRIES:

0-184

GUIDELINES:

· Enter the total number of days in a hospital medical unit from self-harm injuries in the previous six months.

FIELD NUMBER: D5

FIELD LENGTH: 3

FIELD TYPE: Numeric

FORMAT: XXX

VARIABLE NAME: DBT – Medical Admission For Self-Harm Injuries - Times: Preceding 6 Months

DESCRIPTION: Number of episodes the client was seen on an inpatient medical unit for self-harm injuries.

VALID ENTRIES:

0-184

GUIDELINES:

· Enter the total number of episodes that client was admitted on a hospital medical unit for self-harm injuries in previous six months.

FIELD NUMBER: D6

FIELD LENGTH: 3

FIELD TYPE: Numeric

FORMAT: XXX

VARIABLE NAME: DBT – Emergency Room Visits For Behavioral Issues: Preceding 6 Months

DESCRIPTION: Number of episodes the client presented at an urgent care or emergency room for psychiatric reasons, including self-harm/threats of self-harm.

VALID ENTRIES:

0-184

GUIDELINES:

· Enter number of times that client sought help from an emergency room or urgent care with psychiatric symptoms including; self-harm threats or thoughts of self- harm, requests to be admitted to the inpatient psychiatric unit, and misuse of prescription medications or use of street drugs and alcohol which result in emergency room care in the previous six months.

FIELD NUMBER: D7

FIELD LENGTH: 3

FIELD TYPE: Numeric

FORMAT: XXX

VARIABLE NAME: DBT – Suicide Attempts: Preceding 6 Months

DESCRIPTION: Number of suicide attempts or threats.

VALID ENTRIES:

0-184

GUIDELINES:

· Indicate number of episodes of suicide attempt, suicidal thoughts or threats of suicide in the previous six months. This information can be gathered from a client’s DBT diary card or the BSL-Supplement: items for assessing behavior.

FIELD NUMBER: D8

FIELD LENGTH: 3

FIELD TYPE: Numeric

FORMAT: XXX

VARIABLE NAME: DBT – Non-Suicidal Self-Injuries: Preceding 6 Months

DESCRIPTION: Number of self-harm episodes.

VALID ENTRIES:

0-184

GUIDELINES:

· Indicate number of self-harm behaviors as defined as the target behaviors addressed in treatment (cutting, burning, binge eating, vomiting, displayed high- risk behaviors, ingesting prescription medications, illicit chemicals or alcohol, etc.) in the previous six months. This information can be gathered from a client’s DBT diary card or the BSL-Supplement: items for assessing behavior.

FIELD NUMBER: D9

FIELD LENGTH: 3

FIELD TYPE: Numeric

FORMAT: XXX

VARIABLE NAME: DBT – Average Hours Per Week In School: Previous 30 Days

DESCRIPTION: Average number of hours per week client participates in educational activity.

VALID ENTRIES:

[1] None

[2] 1-7 hours

[3] 8-20 hours

[4] 21-31 hours

[5] 32 + hours

[6] School break

GUIDELINES:

· Select the range that represents the average time the client participates in classroom or online coursework in one week.

· Use code [6] School break if client would otherwise be participating in school, but is not due to school-initiated holiday, vacation or break between semesters.

FIELD NUMBER: D10

FIELD LENGTH: 1

FIELD TYPE: Text

FORMAT: X

VARIABLE NAME: DBT – Average Hours Per Week Doing Volunteer Work: Previous 30 Days

DESCRIPTION: Average number of hours per week that client participates in volunteer work activity.

VALID ENTRIES:

[1] None

[2] 1-7 hours

[3] 8-20 hours

[4] 21-31 hours

[5] 32 + hours

GUIDELINES:

· Select the range that represents the average time the client spends at a volunteer job per week.

FIELD NUMBER: D11

FIELD LENGTH: 1

FIELD TYPE: Text

FORMAT: X

VARIABLE NAME: DBT – Average Hours per Week Employed: Previous 30 Days

DESCRIPTION: Average number of hours per week client participates in employment work activity.

VALID ENTRIES:

[1] None

[2] 1-7 hours

[3] 8-20 hours

[4] 21-31 hours

[5] 32 + hours

GUIDELINES:

· Select the range that represents the average time the client spends at any type of paid employment per week.

FIELD NUMBER: D12

FIELD LENGTH: 1

FIELD TYPE: Text

FORMAT: X