Clinical Notation: Documentation for clients in treatment - CASAT

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Treatment Planning• Problem: The client has bereavement issues regardingher brother‟s recent suicide that she believes havecontributed to her continued substance abuse.• Goal: Client will identify bereavement issues in relation tousage.• Objective: Client will complete Exercises 1 through 5(amount & frequency) in “Good Grief” and “Waking upAlive” workbooks by MM/DD/YYYY (duration).• Strategy: Counselor and client will review completedbereavement exercises in individual therapy sessions andwill share problems/progress in group sessions.(Amount, frequency and duration are recorded in the fieldsbelow strategy description.)
Treatment PlanningNOTE: The treatment plan status should be “InProgress” only when the treatment plan isbeing edited. Otherwise, it should be in“Completed” status because the hard copy willhave both the client‟s and the counselor‟ssignatures.
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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
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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 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 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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