Clinical Notation: Documentation for clients in treatment - CASAT

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Outline For Clinical Notation• Client Information gathered during assessment• Progress Notes• What to do• What not to do• What should be included?• Alignment with treatment plan• Treatment Planning• Discharge• Electronic Notation (NHIPPS)Four Modules of approximately 1 hr/each
Interactive Dialogue!
Page 1: CLINICAL NOTATION:DOCUMENTATION FOR
Page 4: IntroductionsSteve McLaughlin, M.S.
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 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
Page 74 and 75:
Master Problem ListTIP: To remove a
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Treatment Planning• An objective
Page 78 and 79:
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
Page 100 and 101:
Intervention EBP“As stated above,
Page 102 and 103:
Intervention EBP Language“Used op
Page 104:
Chart NotesDifferent from Progress
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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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