Clinical Notation: Documentation for clients in treatment - CASAT

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Signatures, Signatures, Signatures!As we shift towards electrical charting, it isimportant to remember to provide signatureson important documents, including:Forms, including consentsTreatment plansAfter care planAfter each charted documentation in hard chartAlso be mindful of crossing through blankforms, and initial/date when correcting
Hard Charts
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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?
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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 and 110: DischargesNOTE: It's important to b
Page 111: Discharge SummariesIdeally to be co
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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