Clinical Notation: Documentation for clients in treatment - CASAT

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Who is SAPTA?The mission of the Substance Abuse Prevention and TreatmentAgency (SAPTA) is to reduce the impact of substance abuse inNevada.Objectives:• Statewide formulation and implementation of a state plan forprevention, intervention, treatment, and recovery ofsubstance abuse.• Statewide coordination and implementation of state andfederal funding for alcohol and drug abuse programs.• Statewide development and publication of standards forcertification and the authority to certify treatment levels ofcare and prevention programs.
SAPTA Accomplishments:• SAPTA serves as the Single State Authority (SSA)for the federal Substance Abuse Prevention andTreatment (SAPT) Block Grant providingsubstance abuse prevention or treatment servicesvia a competitive process to non-profit serviceproviders and governmental organizations.• In state fiscal year 2010, the SAPTA budgettotaled nearly $26.8 million, includingapproximately $16.4 million in federal supportand approximately $10.4 million in state funds.
Page 1: CLINICAL NOTATION:DOCUMENTATION FOR
Page 4: IntroductionsSteve McLaughlin, M.S.
Page 7 and 8: Interactive Dialogue!
Page 9: What is NHIPPS?The Nevada Health In
Page 13 and 14: What‟s in a Treatment Episode?Scr
Page 15 and 16: NOMS• How do clinicians collect t
Page 17 and 18: Screening• Screening is a formal
Page 19 and 20: Assessment-ASI Lite/NHIPPSThe asses
Page 21 and 22: DSM-IV-TR Justification
Page 23 and 24: Scopes of PracticeRemember to Adher
Page 25 and 26: Previous Dx, cont…Diagnose with t
Page 27 and 28: Recommendations for TxThe screening
Page 29 and 30: ASAM/DPC (Placement Criteria)Justif
Page 31 and 32: ASAM/HDPCASAM drives treatment!Init
Page 33 and 34: Justify your Recommendation!Remembe
Page 35 and 36: Prochaska & DiClementeThe Stages of
Page 37 and 38: Stages of ChangePrecontemplationCon
Page 39 and 40: Challenges during AssessmentWhat if
Page 41 and 42: Understanding ResistanceArises from
Page 43 and 44: “MI Sandwich”Remember to use th
Page 45 and 46: Review of M.I.DefinitionOur best cu
Page 47 and 48: “MI Spirit”:• Express Empathy
Page 49 and 50: OARSOpen-ended questionsAffirmation
Page 51 and 52: Affirmation• Recognizing and affi
Page 53 and 54: Examples of Affirmations“This is
Page 55 and 56: Forming Reflections:Use your tone o
Page 57 and 58: “What if I don‟t get it right?
Page 59 and 60: Let your Clients helpTeach you M.I.
Page 61 and 62:
AssessmentKey point: Ongoing assess
Page 64 and 65:
Questions?Any questions on:What is
Page 66 and 67:
Admission-NHIPPSSingle Service Leve
Page 68 and 69:
Admission cont.Additionally, here a
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Treatment PlanA Severity Rating of
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Master Problem List• Once the ass
Page 74 and 75:
Master Problem ListTIP: To remove a
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Treatment Planning• An objective
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Treatment Planning• Problem: The
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Changing the Treatment PlanSingle S
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Changes in the Treatment PlanAgain,
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Add Review
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ASAM ReviewOnce you have reviewed a
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Activity 1: Treatment PlanningChoos
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Progress NotesProgression throughou
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If a Client has a Treatment PlanThe
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Sample of Progress Notes-TopicsExam
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Examples of Observations-EBPGarlen
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Intervention EBP“Counselor taught
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Intervention EBP“As stated above,
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Intervention EBP Language“Used op
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Chart NotesDifferent from Progress
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After Care Plan• What is included
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DischargesNOTE: It's important to b
Page 111 and 112:
Discharge SummariesIdeally to be co
Page 113 and 114:
Hard Charts
Page 115 and 116:
Supervision DocumentationAs a super
Page 117 and 118:
Clinical DocumentationResponsibilit
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Clinical Notation: Documentation for clients in treatment - CASAT

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