Clinical Notation: Documentation for clients in treatment - CASAT

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Sample of Progress Notes-TopicsExamples of TOPICS section of the Progress Notes.Met with Curt for 60 mins. Discussed alcohol abstinence. Began addressingalternative ways he might deal with his physical pain and also enjoyleisure/relaxation without drinking. Driv. Dims. 2, 3, 5.ASAM 2, 3, and 6. Court trial on 4/16, allergies, relationship with father,substance abuse.Met with Garlen for 50 mins. Discussed problems with his impulsivity andreactions to certain things. Addressed self control and thinking errors. Driv.Dims. 3, 6.Met with Eric for 50 mins. Discussed stress related to work, school, and legalresponsibilities. Addressed how he is managing while preventing relapse.Driv. Dims. 3, 5,
Examples of Observations-EBPExamples of OBSERVATIONS section in the Progress notes.Client displayed self-critical thinking. Client was relaxed duringsession, did not dose off, and was actively engaged in therapy.Garlen presented with a bright affect. He still has a high level ofenergy, but it was not distracting today. He was able toengage in meaningful discussions.Eric was noticeably more irritable today and agreed with thereflection when offered. Eric continues to present with adesire to continue making positive changes and shares a lot ofhope.
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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
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Assessment-ASI Lite/NHIPPSThe asses
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DSM-IV-TR Justification
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Scopes of PracticeRemember to Adher
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Previous Dx, cont…Diagnose with t
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Recommendations for TxThe screening
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ASAM/DPC (Placement Criteria)Justif
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ASAM/HDPCASAM drives treatment!Init
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Justify your Recommendation!Remembe
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Prochaska & DiClementeThe Stages of
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Stages of ChangePrecontemplationCon
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Challenges during AssessmentWhat if
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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
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 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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