Embed Size (px)
Citation preview
Clinical Advisor Data Dictionary
Clinical Notes
The information presented in this document is confidential and expected to be used solely in support of the delivery of services to Magellan members. By receipt of this document, each recipient agrees
that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written
consent of Magellan Health, Inc.
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 2
PURPOSE: The purpose of this document is to define a data dictionary for the Clinical Advisor Clinical Notes data extracts. The Progress Notes (Clinical Notes) extracts displays relevant data captured in all progress notes for all clients at a given facility. Data will be delivered in CSV (comma separated values) format. The data dictionary includes the following: Field Name: Name of the field (spaces will be replaced with underscores) Description: Description of the field Type: Data type of the field. Data types are as follows:
Numeric - Numeric field String - Text field DateTime - Date time field Boolean - Boolean field (Y/N)
Length: Maximum length of string field
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 3
CLIENT PROGRESS NOTES [TYPE = CASE MANAGEMENT AND RESIDENTIAL] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Progress_Note_Type Progress Note Type like, Case Management, Residential, Extended Case Management, Group, BHMP or Nursing
String 50
Clinical_Note_Creating_Staff_ID Clinical Note Creating Staff ID String 5
Clinical_Note_Creating_Staff_First_Name Clinical Note Creating Staff First Name String 50
Clinical_Note_Creating_Staff_Middle_Initial Clinical Note Creating Staff Middle Initial String 15
Clinical_Note_Creating_Staff_Last_Name Clinical Note Creating Staff Last Name String 50
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Service_Date Service Date DateTime
Length_In_Minutes Length In Minutes Numeric
Type_Of_Service_Code Type Of Service Code String 5
Type_Of_Service_Description Type Of Service Description String 150
Type_Of_Service_Is_Group_Service? Type Of Service Is Group Service? Boolean
Type_Of_Service_Is_Billable? Type Of Service Is Billable? Boolean
Type_Of_Service_Scheduler_Description Type Of Service Scheduler Description String 50
Group_ID Group ID, if Group Therapy String 10
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 4
CLIENT PROGRESS NOTES [TYPE = CASE MANAGEMENT AND RESIDENTIAL] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Group_Name Group Name, if Group Therapy String 30
Group_Session_Print_Sign_Sheet Group Session Print Sign Sheet, if Group Therapy String 1
Group_Session_Length_In_Minutes Group Session Length In Minutes, if Group Therapy Numeric
Subjective_Note Subjective Note String Max
Objective_Note Objective Note String Max
Intervention_Note Intervention Note String Max
Assessment_Note Assessment Note String Max
Plan_Note Plan Note String Max
General_Note General Note String Max
Staff_Name Staff Name String 40
Staff_Finalized_Date Staff Finalized Date DateTime
Supervisor_Name Supervisor Name String 40
Supervisor_Finalized_Date Supervisor Finalized Date DateTime
Therapist_2_Staff_ID Therapist 2 Staff ID String 5
Therapist_2_Staff_First_Name Therapist 2 Staff First Name String 50
Therapist_2_Staff_Middle_Initial Therapist 2 Staff Middle Initial String 15
Therapist_2_Staff_Last_Name Therapist 2 Staff Last Name String 50
Progress_Note_Creation_Date Progress Note Creation Date DateTime
Progress_Note_Voided_Date Progress Note Voided Date DateTime
Progress_Note_Voided_Reason Progress Note Voided Reason String Max
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 5
CLIENT PROGRESS NOTES [TYPE = CASE MANAGEMENT AND RESIDENTIAL] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Progress_Note_Voided_By_Staff_ID Progress Note Voided By Staff ID String 5
Progress_Note_Voided_By_Staff_First_Name Progress Note Voided By Staff First Name String 50
Progress_Note_Voided_By_Staff_Middle_Initial Progress Note Voided By Staff Middle Initial String 15
Progress_Note_Voided_By_Staff_Last_Name Progress Note Voided By Staff Last Name String 50
Progress_Note_Voided_By_Staff_Name Progress Note Voided By Staff Name String 40
Progress_Note_Billed_Date Progress Note Billed Date DateTime
Progress_Note_Billed_User_ID Progress Note Billed User ID String 10
Appointment_Status ‘Show / Encounterable' or 'No Show / Non-Encounterable' or 'Cancel / Non-Encounterable’
String 64
Progress_Note_First_Print_Date Progress Note First Print Date DateTime
Progress_Note_Duplicated_From_Note_Key Progress Note Duplicated From Note Key Numeric
Start_Time Start Time DateTime
Progress_Note_Note_Page Progress Note Note Page Numeric
Progress_Note_Units_To_Charge Progress Note Units To Charge Numeric
Appointment_with_Staff_ID Appointment with Staff ID String 5
Appointment_with_Staff_First_Name Appointment with Staff First Name String 50
Appointment_with_Staff_Middle_Initial Appointment with Staff Middle Initial String 15
Appointment_with_Staff_Last_Name Appointment with Staff Last Name String 50
Appointment_Date Appointment Date DateTime
Appointment_Time Appointment Time DateTime
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 6
CLIENT PROGRESS NOTES [TYPE = CASE MANAGEMENT AND RESIDENTIAL] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Opportunity Education - Is there an identified need/opportunity for patient education
String Max
Education_Conducted Education - If appropriate, was education conducted String Max
Education_Objective Education - Educational objective String Max
Tools_Used Education - Tools used String Max
Teaching_Method Education - Teaching method employed String Max
Patient_Understanding Education - How patient understanding is assessed String Max
Patient_Utilizes Education - Barriers to patient utilizing learning String Max
Further_Needs Education - Further needs String Max
Overridden_Diagnosis_Code Overridden Diagnosis Code String 6
Overridden_Diagnosis_Code_Description Overridden Diagnosis Code Description String 100
Group_Summary Group Summary String 1000
Service_Urgency_Type Service Urgency Type String 150
Attended Whether the client attended the session? Denoted by any number greater than 0.
Numeric
Client_Type Client Type String 150
Session_Status Session Status String 50
Goal_Source Goal Source, whether the goals were copied from Treatment Plan or not? If they were copied from Treatment Plan then a 'PD' will show otherwise blank.
String 2
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 7
CLIENT PROGRESS NOTES [TYPE = GROUPS] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Progress_Note_Type Progress Note Type like, Case Management, Residential, Extended Case Management, Group, BHMP or Nursing
String 50
Clinical_Note_Creating_Staff_ID Clinical Note Creating Staff ID String 5
Clinical_Note_Creating_Staff_First_Name Clinical Note Creating Staff First Name String 50
Clinical_Note_Creating_Staff_Middle_Initial Clinical Note Creating Staff Middle Initial String 15
Clinical_Note_Creating_Staff_Last_Name Clinical Note Creating Staff Last Name String 50
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Service_Date Service Date DateTime
Length_In_Minutes Length In Minutes Numeric
Type_Of_Service_Code Type Of Service Code String 5
Type_Of_Service_Description Type Of Service Description String 150
Type_Of_Service_Is_Group_Service? Type Of Service Is Group Service? Boolean
Type_Of_Service_Is_Billable? Type Of Service Is Billable? Boolean
Type_Of_Service_Scheduler_Description Type Of Service Scheduler Description String 50
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 8
CLIENT PROGRESS NOTES [TYPE = GROUPS] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Group_ID Group ID, if Group Therapy String 10
Group_Name Group Name, if Group Therapy String 30
Group_Session_Print_Sign_Sheet Group Session Print Sign Sheet, if Group Therapy String 1
Group_Session_Length_In_Minutes Group Session Length In Minutes, if Group Therapy Numeric
Subjective_Note Subjective Note String Max
Objective_Note Objective Note String Max
Intervention_Note Intervention Note String Max
Assessment_Note Assessment Note String Max
Plan_Note Plan Note String Max
General_Note General Note String Max
Staff_Name Staff Name String 40
Staff_Finalized_Date Staff Finalized Date DateTime
Supervisor_Name Supervisor Name String 40
Supervisor_Finalized_Date Supervisor Finalized Date DateTime
Therapist_2_Staff_ID Therapist 2 Staff ID String 5
Therapist_2_Staff_First_Name Therapist 2 Staff First Name String 50
Therapist_2_Staff_Middle_Initial Therapist 2 Staff Middle Initial String 15
Therapist_2_Staff_Last_Name Therapist 2 Staff Last Name String 50
Progress_Note_Creation_Date Progress Note Creation Date DateTime
Progress_Note_Voided_Date Progress Note Voided Date DateTime
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 9
CLIENT PROGRESS NOTES [TYPE = GROUPS] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Progress_Note_Voided_Reason Progress Note Voided Reason String Max
Progress_Note_Voided_By_Staff_ID Progress Note Voided By Staff ID String 5
Progress_Note_Voided_By_Staff_First_Name Progress Note Voided By Staff First Name String 50
Progress_Note_Voided_By_Staff_Middle_Initial Progress Note Voided By Staff Middle Initial String 15
Progress_Note_Voided_By_Staff_Last_Name Progress Note Voided By Staff Last Name String 50
Progress_Note_Voided_By_Staff_Name Progress Note Voided By Staff Name String 40
Progress_Note_Billed_Date Progress Note Billed Date DateTime
Progress_Note_Billed_User_ID Progress Note Billed User ID String 10
Appointment_Status ‘Show / Encounterable' or 'No Show / Non-Encounterable' or 'Cancel / Non-Encounterable’
String 64
Progress_Note_First_Print_Date Progress Note First Print Date DateTime
Progress_Note_Duplicated_From_Note_Key Progress Note Duplicated From Note Key Numeric
Start_Time Start Time DateTime
Progress_Note_Note_Page Progress Note Note Page Numeric
Progress_Note_Units_To_Charge Progress Note Units To Charge Numeric
Appointment_with_Staff_ID Appointment with Staff ID String 5
Appointment_with_Staff_First_Name Appointment with Staff First Name String 50
Appointment_with_Staff_Middle_Initial Appointment with Staff Middle Initial String 15
Appointment_with_Staff_Last_Name Appointment with Staff Last Name String 50
Appointment_Date Appointment Date DateTime
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 10
CLIENT PROGRESS NOTES [TYPE = GROUPS] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Appointment_Time Appointment Time DateTime
Opportunity Education - Is there an identified need/opportunity for patient education
String Max
Education_Conducted Education - If appropriate, was education conducted String Max
Education_Objective Education - Educational objective String Max
Tools_Used Education - Tools used String Max
Teaching_Method Education - Teaching method employed String Max
Patient_Understanding Education - How patient understanding is assessed String Max
Patient_Utilizes Education - Barriers to patient utilizing learning String Max
Further_Needs Education - Further needs String Max
Overridden_Diagnosis_Code Overridden Diagnosis Code String 6
Overridden_Diagnosis_Code_Description Overridden Diagnosis Code Description String 100
Group_Summary Group Summary String 1000
Service_Urgency_Type Service Urgency Type String 150
Attended Whether the client attended the session? Denoted by any number greater than 0.
Numeric
Client_Type Client Type String 150
Session_Status Session Status String 50
Goal_Source Goal Source, whether the goals were copied from Treatment Plan or not? If they were copied from Treatment
String 2
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 11
CLIENT PROGRESS NOTES [TYPE = GROUPS] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Plan then a 'PD' will show otherwise blank.
Appearance_Description Appearance Description String 512
Appearance_Other Appearance other than the one given in the column above. String 30
Substance_Use_Description Substance Use Description String 512
Progress_Towards_Goal_Description Progress Towards Goal Description String 512
Group_Progress_Note_Selection_Appearance Group Progress Note Selection Appearance String 512
Group_Progress_Note_Selection_Affect Group Progress Note Selection Affect String 512
Group_Progress_Note_Selection_Mood Group Progress Note Selection Mood String 512
Group_Progress_Note_Selection_Thought Group Progress Note Selection Thought String 512
Group_Progress_Note_Selection_Behavior Group Progress Note Selection Behavior String 512
Group_Progress_Note_Selection_Substance_Use Group Progress Note Selection Substance Use String 512
Group_Progress_Note_Selection_Intervention Group Progress Note Selection Intervention String 512
Group_Progress_Note_Selection_Progress_Towards_Goal
Group Progress Note Selection Progress Towards Goal String 512
Group_Progress_Note_Selection_Stage Group Progress Note Selection Stage String 512
Group_Progress_Note_Selection_Plan Group Progress Note Selection Plan String 512
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 12
CLIENT PROGRESS NOTES [TYPE = ENHANCED CASE MANAGEMENT] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Progress_Note_Type Progress Note Type like, Case Management, Residential, Extended Case Management, Group, BHMP or Nursing
String 50
Clinical_Note_Creating_Staff_ID Clinical Note Creating Staff ID String 5
Clinical_Note_Creating_Staff_First_Name Clinical Note Creating Staff First Name String 50
Clinical_Note_Creating_Staff_Middle_Initial Clinical Note Creating Staff Middle Initial String 15
Clinical_Note_Creating_Staff_Last_Name Clinical Note Creating Staff Last Name String 50
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Service_Date Service Date DateTime
Length_In_Minutes Length In Minutes Numeric
Type_Of_Service_Code Type Of Service Code String 5
Type_Of_Service_Description Type Of Service Description String 150
Type_Of_Service_Is_Group_Service? Type Of Service Is Group Service? Boolean
Type_Of_Service_Is_Billable? Type Of Service Is Billable? Boolean
Type_Of_Service_Scheduler_Description Type Of Service Scheduler Description String 50
Group_ID Group ID, if Group Therapy String 10
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 13
CLIENT PROGRESS NOTES [TYPE = ENHANCED CASE MANAGEMENT] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Group_Name Group Name, if Group Therapy String 30
Group_Session_Print_Sign_Sheet Group Session Print Sign Sheet, if Group Therapy String 1
Group_Session_Length_In_Minutes Group Session Length In Minutes, if Group Therapy Numeric
Subjective_Note Subjective Note String Max
Objective_Note Objective Note String Max
Intervention_Note Intervention Note String Max
Assessment_Note Assessment Note String Max
Plan_Note Plan Note String Max
General_Note General Note String Max
Staff_Name Staff Name String 40
Staff_Finalized_Date Staff Finalized Date DateTime
Supervisor_Name Supervisor Name String 40
Supervisor_Finalized_Date Supervisor Finalized Date DateTime
Therapist_2_Staff_ID Therapist 2 Staff ID String 5
Therapist_2_Staff_First_Name Therapist 2 Staff First Name String 50
Therapist_2_Staff_Middle_Initial Therapist 2 Staff Middle Initial String 15
Therapist_2_Staff_Last_Name Therapist 2 Staff Last Name String 50
Progress_Note_Creation_Date Progress Note Creation Date DateTime
Progress_Note_Voided_Date Progress Note Voided Date DateTime
Progress_Note_Voided_Reason Progress Note Voided Reason String Max
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 14
CLIENT PROGRESS NOTES [TYPE = ENHANCED CASE MANAGEMENT] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Progress_Note_Voided_By_Staff_ID Progress Note Voided By Staff ID String 5
Progress_Note_Voided_By_Staff_First_Name Progress Note Voided By Staff First Name String 50
Progress_Note_Voided_By_Staff_Middle_Initial Progress Note Voided By Staff Middle Initial String 15
Progress_Note_Voided_By_Staff_Last_Name Progress Note Voided By Staff Last Name String 50
Progress_Note_Voided_By_Staff_Name Progress Note Voided By Staff Name String 40
Progress_Note_Billed_Date Progress Note Billed Date DateTime
Progress_Note_Billed_User_ID Progress Note Billed User ID String 10
Appointment_Status ‘Show / Encounterable' or 'No Show / Non-Encounterable' or 'Cancel / Non-Encounterable’
String 64
Progress_Note_First_Print_Date Progress Note First Print Date DateTime
Progress_Note_Duplicated_From_Note_Key Progress Note Duplicated From Note Key Numeric
Start_Time Start Time DateTime
Progress_Note_Note_Page Progress Note Note Page Numeric
Progress_Note_Units_To_Charge Progress Note Units To Charge Numeric
Appointment_with_Staff_ID Appointment with Staff ID String 5
Appointment_with_Staff_First_Name Appointment with Staff First Name String 50
Appointment_with_Staff_Middle_Initial Appointment with Staff Middle Initial String 15
Appointment_with_Staff_Last_Name Appointment with Staff Last Name String 50
Appointment_Date Appointment Date DateTime
Appointment_Time Appointment Time DateTime
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 15
CLIENT PROGRESS NOTES [TYPE = ENHANCED CASE MANAGEMENT] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Opportunity Education - Is there an identified need/opportunity for patient education
String Max
Education_Conducted Education - If appropriate, was education conducted String Max
Education_Objective Education - Educational objective String Max
Tools_Used Education - Tools used String Max
Teaching_Method Education - Teaching method employed String Max
Patient_Understanding Education - How patient understanding is assessed String Max
Patient_Utilizes Education - Barriers to patient utilizing learning String Max
Further_Needs Education - Further needs String Max
Overridden_Diagnosis_Code Overridden Diagnosis Code String 6
Overridden_Diagnosis_Code_Description Overridden Diagnosis Code Description String 100
Group_Summary Group Summary String 1000
Service_Urgency_Type Service Urgency Type String 150
Attended Whether the client attended the session? Denoted by any number greater than 0.
Numeric
Client_Type Client Type String 150
Session_Status Session Status String 50
Goal_Source Goal Source, whether the goals were copied from Treatment Plan or not? If they were copied from Treatment Plan then a 'PD' will show otherwise blank.
String 2
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 16
CLIENT PROGRESS NOTES [TYPE = ENHANCED CASE MANAGEMENT] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Addon_Service1_Type_Of_Service_Code Addon Service1 Type Of Service Code String 5
Addon_Service1_Type_Of_Service_Description Addon Service1 Type Of Service Description String 150
Addon_Service1_Start_Time Addon Service1 Start Time DateTime
Addon_Service1_End_Time Addon Service1 End Time DateTime
Addon_Service1_Units Addon Service1 Units Numeric
Addon_Service1_Minutes Addon Service1 Minutes Numeric
Addon_Service2_Type_Of_Service_Code Addon Service2 Type Of Service Code String 5
Addon_Service2_Type_Of_Service_Description Addon Service2 Type Of Service Description String 150
Addon_Service2_Start_Time Addon Service2 Start Time DateTime
Addon_Service2_End_Time Addon Service2 End Time DateTime
Addon_Service2_Units Addon Service2 Units Numeric
Addon_Service2_Minutes Addon Service2 Minutes Numeric
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 17
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Progress_Note_Type Progress Note Type like, Case Management, Residential, Extended Case Management, Group, BHMP or Nursing
String 50
Clinical_Note_Creating_Staff_ID Clinical Note Creating Staff ID String 5
Clinical_Note_Creating_Staff_First_Name Clinical Note Creating Staff First Name String 50
Clinical_Note_Creating_Staff_Middle_Initial Clinical Note Creating Staff Middle Initial String 15
Clinical_Note_Creating_Staff_Last_Name Clinical Note Creating Staff Last Name String 50
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Service_Date Service Date DateTime
Length_In_Minutes Length In Minutes Numeric
Type_Of_Service_Code Type Of Service Code String 5
Type_Of_Service_Description Type Of Service Description String 150
Type_Of_Service_Is_Group_Service? Type Of Service Is Group Service? Boolean
Type_Of_Service_Is_Billable? Type Of Service Is Billable? Boolean
Type_Of_Service_Scheduler_Description Type Of Service Scheduler Description String 50
Group_ID Group ID, if Group Therapy String 10
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 18
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Group_Name Group Name, if Group Therapy String 30
Group_Session_Print_Sign_Sheet Group Session Print Sign Sheet, if Group Therapy String 1
Group_Session_Length_In_Minutes Group Session Length In Minutes, if Group Therapy Numeric
Subjective_Note Subjective Note String Max
Objective_Note Objective Note String Max
Intervention_Note Intervention Note String Max
Assessment_Note Assessment Note String Max
Plan_Note Plan Note String Max
General_Note General Note String Max
Staff_Name Staff Name String 40
Staff_Finalized_Date Staff Finalized Date DateTime
Supervisor_Name Supervisor Name String 40
Supervisor_Finalized_Date Supervisor Finalized Date DateTime
Therapist_2_Staff_ID Therapist 2 Staff ID String 5
Therapist_2_Staff_First_Name Therapist 2 Staff First Name String 50
Therapist_2_Staff_Middle_Initial Therapist 2 Staff Middle Initial String 15
Therapist_2_Staff_Last_Name Therapist 2 Staff Last Name String 50
Progress_Note_Creation_Date Progress Note Creation Date DateTime
Progress_Note_Voided_Date Progress Note Voided Date DateTime
Progress_Note_Voided_Reason Progress Note Voided Reason String Max
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 19
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Progress_Note_Voided_By_Staff_ID Progress Note Voided By Staff ID String 5
Progress_Note_Voided_By_Staff_First_Name Progress Note Voided By Staff First Name String 50
Progress_Note_Voided_By_Staff_Middle_Initial Progress Note Voided By Staff Middle Initial String 15
Progress_Note_Voided_By_Staff_Last_Name Progress Note Voided By Staff Last Name String 50
Progress_Note_Voided_By_Staff_Name Progress Note Voided By Staff Name String 40
Progress_Note_Billed_Date Progress Note Billed Date DateTime
Progress_Note_Billed_User_ID Progress Note Billed User ID String 10
Appointment_Status ‘Show / Encounterable' or 'No Show / Non-Encounterable' or 'Cancel / Non-Encounterable’
String 64
Progress_Note_First_Print_Date Progress Note First Print Date DateTime
Progress_Note_Duplicated_From_Note_Key Progress Note Duplicated From Note Key Numeric
Start_Time Start Time DateTime
Progress_Note_Note_Page Progress Note Note Page Numeric
Progress_Note_Units_To_Charge Progress Note Units To Charge Numeric
Appointment_with_Staff_ID Appointment with Staff ID String 5
Appointment_with_Staff_First_Name Appointment with Staff First Name String 50
Appointment_with_Staff_Middle_Initial Appointment with Staff Middle Initial String 15
Appointment_with_Staff_Last_Name Appointment with Staff Last Name String 50
Appointment_Date Appointment Date DateTime
Appointment_Time Appointment Time DateTime
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 20
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Opportunity Education - Is there an identified need/opportunity for patient education
String Max
Education_Conducted Education - If appropriate, was education conducted String Max
Education_Objective Education - Educational objective String Max
Tools_Used Education - Tools used String Max
Teaching_Method Education - Teaching method employed String Max
Patient_Understanding Education - How patient understanding is assessed String Max
Patient_Utilizes Education - Barriers to patient utilizing learning String Max
Further_Needs Education - Further needs String Max
Overridden_Diagnosis_Code Overridden Diagnosis Code String 6
Overridden_Diagnosis_Code_Description Overridden Diagnosis Code Description String 100
Group_Summary Group Summary String 1000
Service_Urgency_Type Service Urgency Type String 150
Attended Whether the client attended the session? Denoted by any number greater than 0.
Numeric
Client_Type Client Type String 150
Session_Status Session Status String 50
Goal_Source Goal Source, whether the goals were copied from Treatment Plan or not? If they were copied from Treatment Plan then a 'PD' will show otherwise blank.
String 2
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 21
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Quick_Note Quick Note Boolean
Quick_Note_Purpose Quick Note Purpose String 25
Quick_Note_Purpose_Explain Quick Note Purpose Explain Text
History_of_Present_Illness_(HPI) History of Present Illness (HPI) Text
Treatment_Adherence Treatment Adherence String 25
Treatment_Adherence_Explain Treatment Adherence Explain Text
Primary_Care_Physician Primary Care Physician String 255
PCP_Phone PCP Phone String 25
PCP_Fax PCP Fax String 25
Medical_Concerns/PCP_Coordination Medical Concerns / PCP Coordination Text
Side_Effects_Severity Side Effects Severity String 100
Tardive_Dyskinesia Tardive Dyskinesia String 25
Side_Effects:EPS Side Effects: EPS Boolean
Side_Effects:Akathesia Side Effects: Akathesia Boolean
Side_Effects:Dystonia Side Effects: Dystonia Boolean
Side_Effects:Anti-Cholinergic Side Effects: Anti-Cholinergic Boolean
Side_Effects:NMS Side Effects: NMS Boolean
Side_Effects:Other Side Effects: Other Boolean
Counseled_Per_Effects/Side_Effects Counseled Per Effects / Side Effects String 25
Side_Effects_Explain Side Effects Explain Text
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 22
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Progress_towards_ISP_Goal:Living Progress towards ISP Goal: Living Text
Progress_towards_ISP_Goal:Work/Learning Progress towards ISP Goal: Work/Learning Text
Progress_towards_ISP_Goal:Social/Leisure Progress towards ISP Goal: Social/Leisure Text
Recent_ETOH/Substances:None Recent ETOH/Substances: None Boolean
Recent_ETOH/Substances:ETOH Recent ETOH/Substances: ETOH Boolean
Recent_ETOH/Substances:Amphetamines Recent ETOH/Substances: Amphetamines Boolean
Recent_ETOH/Substances:Benzodiazepines Recent ETOH/Substances: Benzodiazepines Boolean
Recent_ETOH/Substances:Cannabis Recent ETOH/Substances: Cannabis Boolean
Recent_ETOH/Substances:Nicotine Recent ETOH/Substances: Nicotine Boolean
Recent_ETOH/Substances:Opioids Recent ETOH/Substances: Opioids Boolean
Recent_ETOH/Substances:Steroids Recent ETOH/Substances: Steroids Boolean
Recent_ETOH/Substances:Cocaine Recent ETOH/Substances: Cocaine Boolean
Recent_ETOH/Substances:IV_Use Recent ETOH/Substances: IV Use Boolean
Recent_ETOH/Substances:Hallucinogens Recent ETOH/Substances: Hallucinogens Boolean
Recent_ETOH/Substances:Inhalants Recent ETOH/Substances: Inhalants Boolean
Recent_ETOH/Substances:Narcotic_Pain_Medications
Recent ETOH/Substances: Narcotic Pain Medications Boolean
Recent_ETOH/Substances:ETOH/Substances_Comments
Recent ETOH/Substances: ETOH/Substances Comments Text
Hygiene/Appearance:Good Hygiene/Appearance: Good Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 23
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Hygiene/Appearance:Obese Hygiene/Appearance: Obese Boolean
Hygiene/Appearance:Disheveled Hygiene/Appearance: Disheveled Boolean
Hygiene/Appearance:Unkempt Hygiene/Appearance: Unkempt Boolean
Hygiene/Appearance:Malodorous Hygiene/Appearance: Malodorous Boolean
Hygiene/Appearance:Tattoos Hygiene/Appearance: Tattoos Boolean
Hygiene/Appearance:Thin Hygiene/Appearance: Thin Boolean
Hygiene/Appearance:Average Hygiene/Appearance: Average Boolean
Alertness Alertness String 25
Eye_Contact Eye Contact String 25
Motor:Normal Motor: Normal Boolean
Motor:Hyperactive Motor: Hyperactive Boolean
Motor:Agitated Motor: Agitated Boolean
Motor:Parkinsonian Motor: Parkinsonian Boolean
Motor:Hypoactive Motor: Hypoactive Boolean
Motor:Tremors Motor: Tremors Boolean
Motor:Ataxic Motor: Ataxic Boolean
Motor:Abnormal_movements Motor: Abnormal movements Boolean
Affect:Appropriate Affect: Appropriate Boolean
Affect:Blunted Affect: Blunted Boolean
Affect:Flat Affect: Flat Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 24
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Affect:Labile Affect: Labile Boolean
Affect:Intense Affect: Intense Boolean
Affect:Constricted Affect: Constricted Boolean
Affect:Tearful Affect: Tearful Boolean
Affect:Inappropriate Affect: Inappropriate Boolean
Mood:Euthymic Mood: Euthymic Boolean
Mood:Relaxed Mood: Relaxed Boolean
Mood:Anxious Mood: Anxious Boolean
Mood:Agitated Mood: Agitated Boolean
Mood:Angry Mood: Angry Boolean
Mood:Dysphoric Mood: Dysphoric Boolean
Mood:Elevated Mood: Elevated Boolean
Mood:Euphoric Mood: Euphoric Boolean
Mood:Guarded Mood: Guarded Boolean
Mood:Irritable Mood: Irritable Boolean
Mood:Entitled Mood: Entitled Boolean
Mood:Depressed Mood: Depressed Boolean
Mood:Indifferent Mood: Indifferent Boolean
Mood:Expansive Mood: Expansive Boolean
Speech:Within_Normal_Limits Speech: Within Normal Limits Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 25
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Speech:Loud Speech: Loud Boolean
Speech:Rapid Speech: Rapid Boolean
Speech:Pressured Speech: Pressured Boolean
Speech:Verbose Speech: Verbose Boolean
Speech:Soft Speech: Soft Boolean
Speech:Slow Speech: Slow Boolean
Speech:Monotone Speech: Monotone Boolean
Speech:Impediment Speech: Impediment Boolean
Speech:Slurred Speech: Slurred Boolean
Speech:Impoverished Speech: Impoverished Boolean
Speech:Spontaneous Speech: Spontaneous Boolean
Speech:Other Speech: Other Boolean
Attitude:Cooperative Attitude: Cooperative Boolean
Attitude:Uncooperative Attitude: Uncooperative Boolean
Attitude:Hostile Attitude: Hostile Boolean
Attitude:Friendly Attitude: Friendly Boolean
Attitude:Trustful Attitude: Trustful Boolean
Attitude:Evasive Attitude: Evasive Boolean
Attitude:Suspicious Attitude: Suspicious Boolean
Attitude:Seductive Attitude: Seductive Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 26
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Attitude:Argumentative Attitude: Argumentative Boolean
Attitude:Other Attitude: Other Boolean
Thought_Process_Associations:Logical Thought Process Associations: Logical Boolean
Thought_Process_Associations:Occasionally_Loose Thought Process Associations: Occasionally Loose Boolean
Thought_Process_Associations:Loose Thought Process Associations: Loose Boolean
Thought_Process_Associations:Very_Loose Thought Process Associations: Very Loose Boolean
Thought_Process_Associations:Incomprehensible Thought Process Associations: Incomprehensible Boolean
Thought_Process_Stream:Unremarkable Thought Process Stream: Unremarkable Boolean
Thought_Process_Stream:Circumstantial Thought Process Stream: Circumstantial Boolean
Thought_Process_Stream:Tangential Thought Process Stream: Tangential Boolean
Thought_Process_Stream:Blocking Thought Process Stream: Blocking Boolean
Thought_Process_Stream:Concrete Thought Process Stream: Concrete Boolean
Thought_Content:Non-Psychotic Thought Content: Non-Psychotic Boolean
Thought_Content:Delusions Thought Content: Delusions Boolean
Thought_Content:Alienation Thought Content: Alienation Boolean
Thought_Content:Insertion Thought Content: Insertion Boolean
Thought_Content:Control Thought Content: Control Boolean
Thought_Content:Broadcasting Thought Content: Broadcasting Boolean
Thought_Content:Paranoid Thought Content: Paranoid Boolean
Thought_Content:Help/Hopeless Thought Content: Help / Hopeless Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 27
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Thought_Content:Hyperreligious Thought Content: Hyperreligious Boolean
Thought_Content:Disorganized Thought Content: Disorganized Boolean
Thought_Content:Guilt Thought Content: Guilt Boolean
Thought_Content:Ideas_of_Reference Thought Content: Ideas of Reference Boolean
Thought_Content:Fearful Thought Content: Fearful Boolean
Thought_Content:No_Depr_Content Thought Content: No Depr Content Boolean
Thought_Content:Preoccupations Thought Content: Preoccupations Boolean
Thought_Content:Hypersexual Thought Content: Hypersexual Boolean
Thought_Content:Grandiose Thought Content: Grandiose Boolean
Thought_Content:Obsessions Thought Content: Obsessions Boolean
Thought_Content:Compulsions Thought Content: Compulsions Boolean
Thought_Content:Phobias Thought Content: Phobias Boolean
Risk_of_Harm:None Risk of Harm: None Boolean
Risk_of_Harm:Suicidal Risk of Harm: Suicidal Boolean
Risk_of_Harm:Homicidal Risk of Harm: Homicidal Boolean
Risk_of_Harm:Assaultive Risk of Harm: Assaultive Boolean
Risk_of_Harm:With_Plans/Intent Risk of Harm: With Plans / Intent Boolean
Risk_of_Harm:No_Plans/Intent Risk of Harm: No Plans / Intent Boolean
Risk_of_Harm:Thoughts_of_Death Risk of Harm: Thoughts of Death Boolean
Risk_of_Harm_Comments Risk of Harm Comments Text
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 28
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Perception:Unremarkable Perception: Unremarkable Boolean
Perception:Illusions Perception: Illusions Boolean
Perception:Hallucinations Perception: Hallucinations Boolean
Perception:Hallucinations:Auditory Perception: Hallucinations: Auditory Boolean
Perception:Hallucinations:Visual Perception: Hallucinations: Visual Boolean
Perception:Hallucinations:Other Perception: Hallucinations: Other Boolean
Orientation:Person Orientation: Person String 25
Orientation:Place Orientation: Place String 25
Orientation:Time Orientation: Time String 25
Orientation:Situation Orientation: Situation String 25
Concentration:Good Concentration: Good Boolean
Concentration:Fair Concentration: Fair Boolean
Concentration:Limited Concentration: Limited Boolean
Concentration:Poor Concentration: Poor Boolean
Memory Memory String 25
Intellect:Good Intellect: Good Boolean
Intellect:Fair Intellect: Fair Boolean
Intellect:Poor Intellect: Poor Boolean
Intellect:Limited Intellect: Limited Boolean
Insight:Good Insight: Good Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 29
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Insight:Fair Insight: Fair Boolean
Insight:Poor Insight: Poor Boolean
Insight:Limited Insight: Limited Boolean
Judgment:Good Judgment: Good Boolean
Judgment:Fair Judgment: Fair Boolean
Judgment:Poor Judgment: Poor Boolean
Judgment:Limited Judgment: Limited Boolean
Mental_Status_Page_1_Comments Mental Status Page 1 Comments Text
Mental_Status_Page_2_Comments Mental Status Page 2 Comments Text
Mental_Status_Page_3_Comments Mental Status Page 3 Comments Text
Mental_Status_Page_4_Comments Mental Status Page 4 Comments String Max
Severity_Of_Symptoms Severity Of Symptoms String 100
Global_Improvement Global Improvement String 100
Fax_To_PCP? Fax To PCP? String 1
Return_In Return In String 100
Clinical_Summary Clinical Summary Text
ISP_Required? ISP Required? String 1
For COT Only:Medication_Adherence? For COT Only: Medication_Adherence? Has BHR been non-adherent to medications for a behavioral health disorder for more than 07 days without reasonable cause?
Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 30
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Medication_Adherence_Explanation Medication Adherence Explanation String 68
Patient_Reminder_Sent? Patient Reminder Sent? Boolean
Reminder_Date Reminder Date DateTime
Medication_Documentation Medication Documentation String 25
Suicide_Risk_Assessment? Suicide Risk Assessment? String 1
Clinical_Depression_Screen Clinical Depression Screen String 25
Demographic_Measure Demographic Measure String 128
Addon_Service1_Type_Of_Service_Code Addon Service1 Type Of Service Code String 5
Addon_Service1_Type_Of_Service_Description Addon Service1 Type Of Service Description String 150
Addon_Service1_Start_Time Addon Service1 Start Time DateTime
Addon_Service1_End_Time Addon Service1 End Time DateTime
Addon_Service1_Units Addon Service1 Units Numeric
Addon_Service1_Minutes Addon Service1 Minutes Numeric
Addon_Service2_Type_Of_Service_Code Addon Service2 Type Of Service Code String 5
Addon_Service2_Type_Of_Service_Description Addon Service2 Type Of Service Description String 150
Addon_Service2_Start_Time Addon Service2 Start Time DateTime
Addon_Service2_End_Time Addon Service2 End Time DateTime
Addon_Service2_Units Addon Service2 Units Numeric
Addon_Service2_Minutes Addon Service2 Minutes Numeric
MissingCCDData:Category Missing CCD Data: Category String 150
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 31
CLIENT PROGRESS NOTES [TYPE = BHMP] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
MissingCCDData:Date Missing CCD Data: Date DateTime
MissingCCDData:CodeSystem Missing CCD Data: CodeSystem String 150
MissingCCDData:Code Missing CCD Data: Code String 150
MissingCCDData:Description Missing CCD Data: Description String 500
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 32
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Progress_Note_Type Progress Note Type like, Case Management, Residential, Extended Case Management, Group, BHMP or Nursing
String 50
Clinical_Note_Creating_Staff_ID Clinical Note Creating Staff ID String 5
Clinical_Note_Creating_Staff_First_Name Clinical Note Creating Staff First Name String 50
Clinical_Note_Creating_Staff_Middle_Initial Clinical Note Creating Staff Middle Initial String 15
Clinical_Note_Creating_Staff_Last_Name Clinical Note Creating Staff Last Name String 50
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Service_Date Service Date DateTime
Length_In_Minutes Length In Minutes Numeric
Type_Of_Service_Code Type Of Service Code String 5
Type_Of_Service_Description Type Of Service Description String 150
Type_Of_Service_Is_Group_Service? Type Of Service Is Group Service? Boolean
Type_Of_Service_Is_Billable? Type Of Service Is Billable? Boolean
Type_Of_Service_Scheduler_Description Type Of Service Scheduler Description String 50
Group_ID Group ID, if Group Therapy String 10
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 33
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Group_Name Group Name, if Group Therapy String 30
Group_Session_Print_Sign_Sheet Group Session Print Sign Sheet, if Group Therapy String 1
Group_Session_Length_In_Minutes Group Session Length In Minutes, if Group Therapy Numeric
Subjective_Note Subjective Note String Max
Objective_Note Objective Note String Max
Intervention_Note Intervention Note String Max
Assessment_Note Assessment Note String Max
Plan_Note Plan Note String Max
General_Note General Note String Max
Staff_Name Staff Name String 40
Staff_Finalized_Date Staff Finalized Date DateTime
Supervisor_Name Supervisor Name String 40
Supervisor_Finalized_Date Supervisor Finalized Date DateTime
Therapist_2_Staff_ID Therapist 2 Staff ID String 5
Therapist_2_Staff_First_Name Therapist 2 Staff First Name String 50
Therapist_2_Staff_Middle_Initial Therapist 2 Staff Middle Initial String 15
Therapist_2_Staff_Last_Name Therapist 2 Staff Last Name String 50
Progress_Note_Creation_Date Progress Note Creation Date DateTime
Progress_Note_Voided_Date Progress Note Voided Date DateTime
Progress_Note_Voided_Reason Progress Note Voided Reason String Max
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 34
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Progress_Note_Voided_By_Staff_ID Progress Note Voided By Staff ID String 5
Progress_Note_Voided_By_Staff_First_Name Progress Note Voided By Staff First Name String 50
Progress_Note_Voided_By_Staff_Middle_Initial Progress Note Voided By Staff Middle Initial String 15
Progress_Note_Voided_By_Staff_Last_Name Progress Note Voided By Staff Last Name String 50
Progress_Note_Voided_By_Staff_Name Progress Note Voided By Staff Name String 40
Progress_Note_Billed_Date Progress Note Billed Date DateTime
Progress_Note_Billed_User_ID Progress Note Billed User ID String 10
Appointment_Status ‘Show / Encounterable' or 'No Show / Non-Encounterable' or 'Cancel / Non-Encounterable’
String 64
Progress_Note_First_Print_Date Progress Note First Print Date DateTime
Progress_Note_Duplicated_From_Note_Key Progress Note Duplicated From Note Key Numeric
Start_Time Start Time DateTime
Progress_Note_Note_Page Progress Note Note Page Numeric
Progress_Note_Units_To_Charge Progress Note Units To Charge Numeric
Appointment_with_Staff_ID Appointment with Staff ID String 5
Appointment_with_Staff_First_Name Appointment with Staff First Name String 50
Appointment_with_Staff_Middle_Initial Appointment with Staff Middle Initial String 15
Appointment_with_Staff_Last_Name Appointment with Staff Last Name String 50
Appointment_Date Appointment Date DateTime
Appointment_Time Appointment Time DateTime
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 35
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Opportunity Education - Is there an identified need/opportunity for patient education
String Max
Education_Conducted Education - If appropriate, was education conducted String Max
Education_Objective Education - Educational objective String Max
Tools_Used Education - Tools used String Max
Teaching_Method Education - Teaching method employed String Max
Patient_Understanding Education - How patient understanding is assessed String Max
Patient_Utilizes Education - Barriers to patient utilizing learning String Max
Further_Needs Education - Further needs String Max
Overridden_Diagnosis_Code Overridden Diagnosis Code String 6
Overridden_Diagnosis_Code_Description Overridden Diagnosis Code Description String 100
Group_Summary Group Summary String 1000
Service_Urgency_Type Service Urgency Type String 150
Attended Whether the client attended the session? Denoted by any number greater than 0.
Numeric
Client_Type Client Type String 150
Session_Status Session Status String 50
Goal_Source Goal Source, whether the goals were copied from Treatment Plan or not? If they were copied from Treatment Plan then a 'PD' will show otherwise blank.
String 2
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 36
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Quick_Note Quick Note Numeric
Reason_For_Visit Reason For Visit String Max
Treatment_Adherence Treatment Adherence String 25
Treatment_Adherence_Explain Treatment Adherence Explain String Max
Primary_Care_Physician Primary Care Physician String 255
PCP_Phone PCP Phone String 25
PCP_Fax PCP Fax String 25
Last_PCP_Appointment_Date Last PCP Appointment Date DateTime
Medical_Concerns/PCP_Coordination Medical Concerns / PCP Coordination String Max
Side_Effects_Severity Side Effects Severity String 100
Tardive_Dyskinesia Tardive Dyskinesia String 25
Side_Effects:EPS Side Effects: EPS Boolean
Side_Effects:Akathesia Side Effects: Akathesia Boolean
Side_Effects:Dystonia Side Effects: Dystonia Boolean
Side_Effects:Anti-Cholinergic Side Effects: Anti-Cholinergic Boolean
Side_Effects:NMS Side Effects: NMS Boolean
Side_Effects:Other Side Effects: Other Boolean
Counseled_Per_Effects/Side_Effects Counseled Per Effects / Side Effects String 25
Side_Effects_Explain Side Effects Explain String Max
Progress_towards_ISP_Goal:Living Progress towards ISP Goal: Living String Max
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 37
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Progress_towards_ISP_Goal:Work/Learning Progress towards ISP Goal: Work/Learning String Max
Progress_towards_ISP_Goal:Social/Leisure Progress towards ISP Goal: Social/Leisure String Max
Recent_ETOH/Substances:None Recent ETOH/Substances: None Boolean
Recent_ETOH/Substances:ETOH Recent ETOH/Substances: ETOH Boolean
Recent_ETOH/Substances:Amphetamines Recent ETOH/Substances: Amphetamines Boolean
Recent_ETOH/Substances:Benzodiazepines Recent ETOH/Substances: Benzodiazepines Boolean
Recent_ETOH/Substances:Cannabis Recent ETOH/Substances: Cannabis Boolean
Recent_ETOH/Substances:Nicotine Recent ETOH/Substances: Nicotine Boolean
Recent_ETOH/Substances:Opioids Recent ETOH/Substances: Opioids Boolean
Recent_ETOH/Substances:Steroids Recent ETOH/Substances: Steroids Boolean
Recent_ETOH/Substances:Cocaine Recent ETOH/Substances: Cocaine Boolean
Recent_ETOH/Substances:IV_Use Recent ETOH/Substances: IV Use Boolean
Recent_ETOH/Substances:Hallucinogens Recent ETOH/Substances: Hallucinogens Boolean
Recent_ETOH/Substances:Inhalants Recent ETOH/Substances: Inhalants Boolean
Recent_ETOH/Substances:Narcotic_Pain_Medications
Recent ETOH/Substances: Narcotic Pain Medications Boolean
Recent_ETOH/Substances:ETOH/Substances_Comments
Recent ETOH/Substances: ETOH/Substances Comments String Max
Hygiene/Appearance:Good Hygiene/Appearance: Good Boolean
Hygiene/Appearance:Obese Hygiene/Appearance: Obese Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 38
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Hygiene/Appearance:Disheveled Hygiene/Appearance: Disheveled Boolean
Hygiene/Appearance:Unkempt Hygiene/Appearance: Unkempt Boolean
Hygiene/Appearance:Malodorous Hygiene/Appearance: Malodorous Boolean
Hygiene/Appearance:Tattoos Hygiene/Appearance: Tattoos Boolean
Hygiene/Appearance:Thin Hygiene/Appearance: Thin Boolean
Hygiene/Appearance:Average Hygiene/Appearance: Average Boolean
Alertness Alertness String 25
Eye_Contact Eye Contact String 25
Motor:Normal Motor: Normal Boolean
Motor:Hyperactive Motor: Hyperactive Boolean
Motor:Agitated Motor: Agitated Boolean
Motor:Parkinsonian Motor: Parkinsonian Boolean
Motor:Hypoactive Motor: Hypoactive Boolean
Motor:Tremors Motor: Tremors Boolean
Motor:Ataxic Motor: Ataxic Boolean
Motor:Abnormal_movements Motor: Abnormal movements Boolean
Nursing_Assessment_Page_1_Comments Nursing Assessment Page 1 Comments String Max
Affect:Appropriate Affect: Appropriate Boolean
Affect:Blunted Affect: Blunted Boolean
Affect:Flat Affect: Flat Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 39
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Affect:Labile Affect: Labile Boolean
Affect:Intense Affect: Intense Boolean
Affect:Constricted Affect: Constricted Boolean
Affect:Tearful Affect: Tearful Boolean
Affect:Inappropriate Affect: Inappropriate Boolean
Mood:Euthymic Mood: Euthymic Boolean
Mood:Relaxed Mood: Relaxed Boolean
Mood:Anxious Mood: Anxious Boolean
Mood:Agitated Mood: Agitated Boolean
Mood:Angry Mood: Angry Boolean
Mood:Dysphoric Mood: Dysphoric Boolean
Mood:Elevated Mood: Elevated Boolean
Mood:Euphoric Mood: Euphoric Boolean
Mood:Guarded Mood: Guarded Boolean
Mood:Irritable Mood: Irritable Boolean
Mood:Entitled Mood: Entitled Boolean
Mood:Depressed Mood: Depressed Boolean
Mood:Indifferent Mood: Indifferent Boolean
Mood:Expansive Mood: Expansive Boolean
Speech:Within_Normal_Limits Speech: Within Normal Limits Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 40
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Speech:Loud Speech: Loud Boolean
Speech:Rapid Speech: Rapid Boolean
Speech:Pressured Speech: Pressured Boolean
Speech:Verbose Speech: Verbose Boolean
Speech:Soft Speech: Soft Boolean
Speech:Slow Speech: Slow Boolean
Speech:Monotone Speech: Monotone Boolean
Speech:Impediment Speech: Impediment Boolean
Speech:Slurred Speech: Slurred Boolean
Speech:Impoverished Speech: Impoverished Boolean
Speech:Spontaneous Speech: Spontaneous Boolean
Speech:Other Speech: Other Boolean
Attitude:Cooperative Attitude: Cooperative Boolean
Attitude:Uncooperative Attitude: Uncooperative Boolean
Attitude:Hostile Attitude: Hostile Boolean
Attitude:Friendly Attitude: Friendly Boolean
Attitude:Trustful Attitude: Trustful Boolean
Attitude:Evasive Attitude: Evasive Boolean
Attitude:Suspicious Attitude: Suspicious Boolean
Attitude:Seductive Attitude: Seductive Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 41
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Attitude:Argumentative Attitude: Argumentative Boolean
Attitude:Other Attitude: Other Boolean
Nursing_Assessment_Page_2_Comments Nursing Assessment Page 2 Comments String Max
Risk_of_Harm:None Risk of Harm: None Boolean
Risk_of_Harm:Suicidal Risk of Harm: Suicidal Boolean
Risk_of_Harm:Homicidal Risk of Harm: Homicidal Boolean
Risk_of_Harm:Assaultive Risk of Harm: Assaultive Boolean
Risk_of_Harm:With_Plans/Intent Risk of Harm: With Plans / Intent Boolean
Risk_of_Harm:No_Plans/Intent Risk of Harm: No Plans / Intent Boolean
Risk_of_Harm:Thoughts_of_Death Risk of Harm: Thoughts of Death Boolean
Risk_of_Harm_Comments Risk of Harm Comments String Max
Thought_Process_Associations:Logical Thought Process Associations: Logical Boolean
Thought_Process_Associations:Occasionally_Loose Thought Process Associations: Occasionally Loose Boolean
Thought_Process_Associations:Loose Thought Process Associations: Loose Boolean
Thought_Process_Associations:Very_Loose Thought Process Associations: Very Loose Boolean
Thought_Process_Associations:Incomprehensible Thought Process Associations: Incomprehensible Boolean
Thought_Process_Stream:Unremarkable Thought Process Stream: Unremarkable Boolean
Thought_Process_Stream:Circumstantial Thought Process Stream: Circumstantial Boolean
Thought_Process_Stream:Tangential Thought Process Stream: Tangential Boolean
Thought_Process_Stream:Blocking Thought Process Stream: Blocking Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 42
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Thought_Process_Stream:Concrete Thought Process Stream: Concrete Boolean
Thought_Content:Non-Psychotic Thought Content: Non-Psychotic Boolean
Thought_Content:Delusions Thought Content: Delusions Boolean
Thought_Content:Alienation Thought Content: Alienation Boolean
Thought_Content:Insertion Thought Content: Insertion Boolean
Thought_Content:Control Thought Content: Control Boolean
Thought_Content:Broadcasting Thought Content: Broadcasting Boolean
Thought_Content:Paranoid Thought Content: Paranoid Boolean
Thought_Content:Help/Hopeless Thought Content: Help / Hopeless Boolean
Thought_Content:Hyperreligious Thought Content: Hyperreligious Boolean
Thought_Content:Disorganized Thought Content: Disorganized Boolean
Thought_Content:Guilt Thought Content: Guilt Boolean
Thought_Content:Ideas_of_Reference Thought Content: Ideas of Reference Boolean
Thought_Content:Fearful Thought Content: Fearful Boolean
Thought_Content:No_Depr_Content Thought Content: No Depr Content Boolean
Thought_Content:Preoccupations Thought Content: Preoccupations Boolean
Thought_Content:Hypersexual Thought Content: Hypersexual Boolean
Thought_Content:Grandiose Thought Content: Grandiose Boolean
Thought_Content:Obsessions Thought Content: Obsessions Boolean
Thought_Content:Compulsions Thought Content: Compulsions Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 43
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Thought_Content:Phobias Thought Content: Phobias Boolean
Nursing_Assessment_Page_3_Comments Nursing Assessment Page 3 Comments String Max
Perception:Unremarkable Perception: Unremarkable Boolean
Perception:Illusions Perception: Illusions Boolean
Perception:Hallucinations Perception: Hallucinations Boolean
Perception:Hallucinations:Auditory Perception: Hallucinations: Auditory Boolean
Perception:Hallucinations:Visual Perception: Hallucinations: Visual Boolean
Perception:Hallucinations:Other Perception: Hallucinations: Other Boolean
Orientation:Person Orientation: Person String 25
Orientation:Place Orientation: Place String 25
Orientation:Time Orientation: Time String 25
Orientation:Situation Orientation: Situation String 25
Concentration:Good Concentration: Good Boolean
Concentration:Fair Concentration: Fair Boolean
Concentration:Limited Concentration: Limited Boolean
Concentration:Poor Concentration: Poor Boolean
Memory Memory String 25
Intellect:Good Intellect: Good Boolean
Intellect:Fair Intellect: Fair Boolean
Intellect:Poor Intellect: Poor Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 44
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
Intellect:Limited Intellect: Limited Boolean
Insight:Good Insight: Good Boolean
Insight:Fair Insight: Fair Boolean
Insight:Poor Insight: Poor Boolean
Insight:Limited Insight: Limited Boolean
Judgment:Good Judgment: Good Boolean
Judgment:Fair Judgment: Fair Boolean
Judgment:Poor Judgment: Poor Boolean
Judgment:Limited Judgment: Limited Boolean
Nursing_Assessment_Page_4_Comments Nursing Assessment Page 4 Comments String Max
Describe_Sleep Describe Sleep String 250
Physical_Exercise_(Frequency) Physical Exercise (Frequency) String 25
Smoking_Status_SNOMED_ID Smoking Status SNOMED ID String 50
Smoking_Status_Code Smoking Status Code String 50
Smoking_Status_Description Smoking Status Description String 500
Packs_Per_Day Packs Per Day Numeric
Social/Leisure_Activity Social / Leisure Activity String 50
Meals_Per_Day Meals Per Day String 25
Nursing_Assessment Nursing Assessment String Max
Nursing_Plan_And_Recommendation Nursing Plan And Recommendation String Max
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 45
CLIENT PROGRESS NOTES [TYPE = NURSING] EXTRACT
FIELD NAME DESCRIPTION TYPE LENGTH
ISP_Required? ISP Required? String 1
Fax_To_PCP? Fax To PCP? String 1
In_Lieu_Of_Services_Indicator In Lieu Of Services Indicator Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 46
LAB ORDERS
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Lab_Order_Date Lab Order Date DateTime
Result_Date Result Date DateTime
Unsigned Unsigned Boolean
Unread_Comment Unread Comment Boolean
Abnormal Result Abnormal Result Boolean
Tests_Ordered Tests Ordered String 1000
CreatedBy_Therapist_ID Created By Therapist ID String 5
CreatedBy_Therapist_First_Name Created By Therapist First Name String 50
CreatedBy_Therapist_Middle_Initial Created By Therapist Middle Initial String 15
CreatedBy_Therapist_Last_Name Created By Therapist Last Name String 50
Draw_Create_Date Draw Create Date DateTime
Standing? Standing Order? As an example, if it is a routine or recurring lab orders?
Boolean
Stat Stat Order? STAT Tests are those where test results that Boolean
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 47
LAB ORDERS
FIELD NAME DESCRIPTION TYPE LENGTH
are urgently needed for the diagnosis or treatment of the patient. The delay can be life threatening.
PNO_Medical_Director_Approved Approved by PNO Medical Director? Boolean
Lab_Sample_Drawn_Status_Desc Lab Sample Drawn Status Description String 50
Draw_Date Draw Date DateTime
Draw_Time Draw Time DateTime
Fasting? Fasting? Boolean
Draw_Urine_Vol Draw Urine Vol Numeric
Draw_Hours_Post_Dose Draw Hours Post Dose Numeric
Draw_Comments Draw Comments String 1000
Sample_Drawn_By_Therapist_ID Sample Drawn By Therapist ID String 5
Sample_Drawn_By_Therapist_First_Name Sample Drawn By Therapist First Name String 50
Sample_Drawn_By_Therapist_Middle_Initial Sample Drawn By Therapist Middle Initial String 15
Sample_Drawn_By_Therapist_Last_Name Sample Drawn By Therapist Last Name String 50
Clinical_Rationale/Other_Notes Clinical Rationale/Other Notes String 1000
Principal_Diagnosis_Code Principal Diagnosis Code String 6
Principal_Diagnosis_Description Principal Diagnosis Description String 255
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 48
LAB ORDER - TESTS ORDERED
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Lab_Order_Date Lab Order Date DateTime
Lab_Test_Type Lab Test Type String 255
Test_Name Test Name String 255
Test_Short_Name Test Short Name String 255
Test_CPT_Code Test CPT Code String Max
Test_Includes Test Includes String Max
Test_Ask_On_Entry Test Ask On Entry String 50
Test_Specimen_Type Test Specimen Type String Max
Test_Specimen_Volume Test Specimen Volume String Max
Test_Specimen_Minimum_Volume Test Specimen Minimum Volume String Max
Test_Specimen_Container Test Specimen Container String Max
Test_Specimen_Collection Test Specimen Collection String Max
Test_Specimen_Storage Test Specimen Storage String Max
Test_Specimen_Special_Instructions Test Specimen Special Instructions String Max
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 49
LAB ORDER - TESTS ORDERED
FIELD NAME DESCRIPTION TYPE LENGTH
Test_Specimen_Method Test Specimen Method String Max
Test_Specimen_Testing_Frequency Test Specimen Testing Frequency String Max
AIMS (Activity Information Mappings)
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
AIMS_Recording_Date AIMS Recording Date DateTime
Facial_and_Oral_Movements:Muscles Facial and Oral Movements: Muscles - Muscles of Facial Expression (e.g. movement of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling, grimacing)
String 50
Facial_and_Oral_Movements:Lips Facial and Oral Movements: Lips - Lips and Perioral Area (e.g. puckering, pouting, smacking)
String 50
Facial_and_Oral_Movements:Jaw Facial and Oral Movements: Jaw - Jaw (e.g. biting, clenching, chewing, mouth opening, lateral movement)
String 50
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 50
AIMS (Activity Information Mappings)
FIELD NAME DESCRIPTION TYPE LENGTH
Facial_and_Oral_Movements:Tongue Facial and Oral Movements: Tongue - Tongue (rate only increase in movement both in and out of mouth. NOT inability to sustain movement)
String 50
Extremity_Movements:Upper Extremity Movements: Upper - Upper (arms, wrists, hands, fingers). Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous), athetoid movements (i.e. slow, irregular, complex, serpentine). Do NOT include tremor (i.e. repetitive, regular, rythmic).
String 50
Extremity_Movements:Lower Extremity Movements: Lower - Lower (legs, knees, ankles, toes, i.e. lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot).
String 50
Trunk_Movements Trunk Movements - Neck, shoulders, hips (e.g. rocking, twisting, squirming, pelvic gyrations)
String 50
Global_Judgments:Severity Global Judgments: Severity - Severity of abnormal movements
String 50
Global_Judgments:Incapacitation Global Judgments: Incapacitation - Incapacitation due to abnormal movements
String 50
Global_Judgments:Awareness Global Judgments: Awareness - Patient's awareness of abnormal movements (Rate only patient's report)
String 50
Dental_Status:Teeth Dental Status: Teeth - Current problem with teeth and / or String 50
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 51
AIMS (Activity Information Mappings)
FIELD NAME DESCRIPTION TYPE LENGTH
dentures?
Dental_Status:Dentures Dental Status: Dentures - Does patient usually wear dentures?
String 50
Dental_Status:Explain Dental Status: Explain - Descriptive Explanation of Dental Status
String 500
InsertDate InsertDate DateTime
UpdateDate UpdateDate DateTime
InsertedBy Therapist ID Inserted By Therapist ID String 5
InsertedBy Therapist First Name Inserted By Therapist First Name String 50
InsertedBy Therapist Middle Initial Inserted By Therapist Middle Initial String 15
InsertedBy Therapist Last Name Inserted By Therapist Last Name String 50
UpdatedBy Therapist ID Updated By Therapist ID String 5
UpdatedBy Therapist First Name Updated By Therapist First Name String 50
UpdatedBy Therapist Middle Initial Updated By Therapist Middle Initial String 15
UpdatedBy Therapist Last Name Updated By Therapist Last Name String 50
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 52
CLIENT VITALS
FIELD NAME DESCRIPTION TYPE LENGTH
Provider_Code Provider Code Numeric
Facility_Description Facility Description String 150
Client_ID Client ID String 20
Client_First_Name Client First Name String 20
Client_Middle_Initial Client Middle Initial String 20
Client_Last_Name Client Last Name String 30
Client_Vitals_Recording_Date Client Vitals Recording Date DateTime
Temperature Temperature String 10
Pulse Pulse String 10
BloodPressure Blood Pressure String 10
Height Height String 10
Weight Weight String 10
BMI BMI String 10
Waist Waist String 100
InsertDate Insert Date DateTime
UpdateDate Update Date DateTime
BPSystolic BP Systolic Numeric
BPDiastolic BP Diastolic Numeric
RespiratoryRate Respiratory Rate Numeric
InsertedBy Therapist ID Inserted By Therapist ID String 5
Data Dictionary – Clinical Notes
Magellan Confidential and Proprietary Information 53
CLIENT VITALS
FIELD NAME DESCRIPTION TYPE LENGTH
InsertedBy Therapist First Name Inserted By Therapist First Name String 50
InsertedBy Therapist Middle Initial Inserted By Therapist Middle Initial String 15
InsertedBy Therapist Last Name Inserted By Therapist Last Name String 50
UpdatedBy Therapist ID Updated By Therapist ID String 5
UpdatedBy Therapist First Name Updated By Therapist First Name String 50
UpdatedBy Therapist Middle Initial Updated By Therapist Middle Initial String 15
UpdatedBy Therapist Last Name Updated By Therapist Last Name String 50
