Clinical Notation: Documentation for clients in treatment - CASAT

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ASAM PPC-2RThe American Society of Addiction Medicine's(ASAM) Patient Placement Criteria (ASAM PPC-2R) is the most widely used and comprehensivenational guidelines for placement, continued stayand discharge of patients with alcohol and otherdrug problems.The ASAM PPC-2R provides two sets of guidelines,one for adults and one for adolescents, and fivebroad levels of care for each group. Within thesebroad levels of service is a range of specific levelsof care.
ASAM/DPC (Placement Criteria)Justification for level of care.Dimension 1: Acute Intoxication/Withdrawal PotentialDimension 2: Biomedical Conditions and ComplicationsDimension 3: Emotional/Behavioral/Cognitive Conditions andComplicationsDimension 4: Readiness to ChangeDimension 5: Relapse/Continued Use/Continued Problem PotentialDimension 6: Recovery EnvironmentASAM Criteria should be utilized to:1. Assign the appropriate level of service and level of care2. Do effective treatment planning and documentation3. Make decisions about continued service or discharge by ongoingassessment and review of progress notes
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 and 26: Previous Dx, cont…Diagnose with t
Page 27: Recommendations for TxThe screening
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
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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
Page 115 and 116:
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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