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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.
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AssessmentKey point: Ongoing assess
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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
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- Page 107 and 108: After Care Plan• What is included
- Page 109 and 110: DischargesNOTE: It's important to b
- Page 111 and 112: Discharge SummariesIdeally to be co
- Page 113 and 114: Hard Charts
- Page 115: Supervision DocumentationAs a super