Clinical Notation: Documentation for clients in treatment - CASAT

More documents

Recommendations

Info

Chart NotesDifferent from Progress notes (also capturesComprehensive evaluation units)Can be personalizedTo be used as necessary-helps withcommunicationCannot be deleted, however, can be editedOften used to <strong>in</strong>dicate lab results,communication with client, cancellations, etc.
Page 1:
CLINICAL NOTATION:DOCUMENTATION FOR
Page 4:
IntroductionsSteve McLaughlin, M.S.
Page 7 and 8:
Interactive Dialogue!
Page 9 and 10:
What is NHIPPS?The Nevada Health In
Page 11 and 12:
SAPTA Accomplishments:• SAPTA ser
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
Page 70 and 71: Treatment PlanA Severity Rating of
Page 72 and 73: Master Problem List• Once the ass
Page 74 and 75: Master Problem ListTIP: To remove a
Page 76 and 77: Treatment Planning• An objective
Page 78 and 79: Treatment Planning• Problem: The
Page 80 and 81: Changing the Treatment PlanSingle S
Page 82 and 83: Changes in the Treatment PlanAgain,
Page 84 and 85: Add Review
Page 86 and 87: ASAM ReviewOnce you have reviewed a
Page 88 and 89: Activity 1: Treatment PlanningChoos
Page 90 and 91: Progress NotesProgression throughou
Page 92 and 93: If a Client has a Treatment PlanThe
Page 94 and 95: Sample of Progress Notes-TopicsExam
Page 96 and 97: Examples of Observations-EBPGarlen
Page 98 and 99: Intervention EBP“Counselor taught
Page 100 and 101: Intervention EBP“As stated above,
Page 102 and 103: Intervention EBP Language“Used op
Page 106 and 107: Module 4• Aftercare Plan• Disch
Page 108 and 109: DischargesDischarges are filled out
Page 110 and 111: Discharge SummaryWhat is included i
Page 112 and 113: Signatures, Signatures, Signatures!
Page 114 and 115: Hard ChartsOrganizedCoincide with e
Page 116 and 117: Activity 2: You‟re the Supervisor
Page 118: In Conclusion….Questions???
show all

Clinical Notation: Documentation for clients in treatment - CASAT

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?