Clinical Notation: Documentation for clients in treatment - CASAT

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IntroductionTen NOMs Domains• Reduced symptomatology from mental illnesses or abstinencefrom drug use and alcohol abuse• Getting and keeping a job or enrolling and staying in school• Decreasing involvement with the criminal justice system• Finding safe and stable housing• Improving social connectedness to others in the community• Increased access to services• Retention in substance abuse treatment or decreasedinpatient hospitalizations for mental health treatment• Client perception of care• Cost-effectiveness• Use of evidence-based treatment practices
NOMS• How do clinicians collect the NOMs data?• Generally, authorized system users log into NHIPPS andenter the client data directly. In case of a system outage,SAPTA does provide paper-based forms that match allscreens that system users complete in the system. Usuallyclinical staff enter all of the information associated with thetreatment life cycle including:• Substance and Gambling Screening information• The ASI-Lite Assessment information• Division Placement Criteria (DPC)• Admission and Discharge Data• Treatment plans, progress notes, and treatment plan reviews• Waitlist and interim services tracking information
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: What‟s in a Treatment Episode?Scr
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
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Admission-NHIPPSSingle Service Leve
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Admission cont.Additionally, here a
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Treatment PlanA Severity Rating of
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Master Problem List• Once the ass
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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
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Discharge SummariesIdeally to be co
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Hard Charts
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Supervision DocumentationAs a super
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Clinical DocumentationResponsibilit
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Clinical Notation: Documentation for clients in treatment - CASAT

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