Clinical Notation: Documentation for clients in treatment - CASAT

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Comprehensive Evaluations• Within scope of practice of assessing clinician• Include the diagnoses, justification of dx, andv-codes (if applicable)• Keep in mind, identified areas of concern(medical, family, mental health, substance use,employment, etc.) need to be reflected in theASAM/HDPC summary and treatment plan
Recommendations for TxThe screening and assessments havebeen completed…now what???
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 and 24: Scopes of PracticeRemember to Adher
Page 25: Previous Dx, cont…Diagnose with t
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
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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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