Clinical Notation: Documentation for clients in treatment - CASAT

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DSM-IV DiagnosingDSM-IV diagnosis must be justified and detailedIf there is a rule/out-monitor throughout txepisodeUtilize V-codes when warranted
Scopes of PracticeRemember to Adhere to Regulations of theLicensing boards regarding scopes ofpracticeRefer, if necessaryIf LADC/CADC/CADC intern-can addressitems related to substance use
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: DSM-IV-TR Justification
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 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 and 112:
Discharge SummariesIdeally to be co
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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