Clinical Notation: Documentation for clients in treatment - CASAT

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Discharge SummaryWhat is included in a discharge summary?If the client successfully completes treatmentIf the client is transferred to a different level ofcareIf the client stopped attending sessionsaltogether (no call/no show)If the client left residential services AMAIf the client became incarcerated for over 30days
Discharge SummariesIdeally to be completed with the client as itincludes goals for continuum of careIs detailed so client can understand any furtherrecommendationsCan include identified strategies for relapsepreventionIs MeasurableIncludes pertinent information regarding DSM-IV dx, completion of treatment, follow-upinstructions
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CLINICAL NOTATION:DOCUMENTATION FOR
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IntroductionsSteve McLaughlin, M.S.
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Interactive Dialogue!
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What is NHIPPS?The Nevada Health In
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SAPTA Accomplishments:• SAPTA ser
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What‟s in a Treatment Episode?Scr
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NOMS• How do clinicians collect t
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Screening• Screening is a formal
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Assessment-ASI Lite/NHIPPSThe asses
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DSM-IV-TR Justification
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Scopes of PracticeRemember to Adher
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Previous Dx, cont…Diagnose with t
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Recommendations for TxThe screening
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ASAM/DPC (Placement Criteria)Justif
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ASAM/HDPCASAM drives treatment!Init
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Justify your Recommendation!Remembe
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Prochaska & DiClementeThe Stages of
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Stages of ChangePrecontemplationCon
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Challenges during AssessmentWhat if
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Understanding ResistanceArises from
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“MI Sandwich”Remember to use th
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Review of M.I.DefinitionOur best cu
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“MI Spirit”:• Express Empathy
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OARSOpen-ended questionsAffirmation
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Affirmation• Recognizing and affi
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Examples of Affirmations“This is
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Forming Reflections:Use your tone o
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“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 104: Chart NotesDifferent from Progress
Page 107 and 108: After Care Plan• What is included
Page 109: DischargesNOTE: It's important to b
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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