Clinical Notation: Documentation for clients in treatment - CASAT

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Treatment PlanA Severity Rating of six or greater in anyassessment category will automatically createan associated problem in the Treatment Planfor any answer that is not a default value, suchas zero or “None Selected.” Likert scale ratingsof Moderate or higher will typically result in aproblem being automatically generated in theTreatment Plan.
Treatment PlanningIn Brief:First Treatment plan to be completed by thirdclinical contactIdentifies progress in client‟s treatment episodeReflects changes in client progressIs to be reviewed at a minimum of every 14/30daysIs to be signed by the client (and markedcomplete if in NHIPPS)
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CLINICAL NOTATION:DOCUMENTATION FOR
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IntroductionsSteve McLaughlin, M.S.
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Interactive Dialogue!
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What is NHIPPS?The Nevada Health In
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SAPTA Accomplishments:• SAPTA ser
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What‟s in a Treatment Episode?Scr
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NOMS• How do clinicians collect t
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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
Page 66 and 67: Admission-NHIPPSSingle Service Leve
Page 68 and 69: Admission cont.Additionally, here a
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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