Clinical Notation: Documentation for clients in treatment - CASAT

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Previous DiagnosisBe mindful of co-occurring issuesConsider impact of substance use (activeuse or withdrawal symptoms could mimicmental health disorders)Ask specifics of any previous mental healthdx (document when, who, where) andsuggest consents to contact previousproviders
Previous Dx, cont…Diagnose with the least restrictive dx (onecan r/o a Dependence dx)Do not change a Dependence dx back to anAbuse dx (despite length of abstinence)Include dx specifiers (ex: “304.30 CannabisDependence, Early Full Remission-in acontrolled environment”)
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 and 22: DSM-IV-TR Justification
Page 23: Scopes of PracticeRemember to Adher
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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