CADC

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Clinical Documentation

-Screening

-Assessment

-Initial Tx plan

-Individualized Tx plan

-Progress Notes

-Discharge Summary

Clinical Documentation Purpose

\-Documents assessments/differential dx and tx and decision making

\-Basis of cont. care/ helps w/ transition process

\-Assists with risks assessments

\-Documents compliance legally, regulatory, institutional.,etc.

\-Facilitates quality assurance

\-Facilitates coordination of efforts between members of tx team

Documentation as a clinical tool

\-Details of cx receiving services

\-Why services needed

\-Who delivered services

\-Outcomes achieved

\-Used in supervision

*Most important skill in assuring cont. of care*

Clinical record

Used as a tool for counselor supervision providing evidence of competence in providing appropriate care

Elements of clinical documentation

\-Clear writing

\-Objective

\-Describes behavioral terms

\-Avoids Jargon/keep simple

\-Concise

\-Positive

Facilitating quality assurance in clinical documentation

-Sustain needs for further assessment, tests, and/or tx

-Improves quality of services

-Adds methods to improve and assure quality care

-Provides information for development and program planning

-Provides dad for development in education and professionally

Types of Documentations

\-Screening

\-Intervention

\-Treatment

\-Administrative

\-Medical

\-Clinical

What to prepare in documentation

\-Recommendations/referrals

\-Case consultations

\-Legal reports

\-Discharge summary

Roles of documentation

\-Clinical tool

\-Continuity of care

\-Legal documentation

\-Accountability

\-Quality assurance

Documentation as Accountability

\-Record information used for billing purposes, financial audits, or reviews to ensure compliance with various standards

* Document:
* Time/Date
* Duration
* Type of Insurance

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Legal Documentation

Records both counselors and client input including what did and did not work. Portion of client records may be requested by the courts if client is legally involved or in a case client brings legal proceedings against counselor/program

How long Illinois medical records are retained

5 years

In Illinois how long are medical records detained

7 years

Comprehensive assessment

Biopsychosocial assessment based on observations and experience from counselors a clinical summary is formulated

Elements of screening documentation

\-Referral sources

\-Presenting problems

\-Background information (vocational, legal, family, living, etc.)

\-Emotional/Mental status (degree of danger or ability to participate in Tx)

\-Client strengths and preferences

\-Recommendation for assessment or another referral

Screening

Occurs in initial contact

Purpose is to gather information to evaluate needs for services, eligibility for services, appropriate level of care and service placement

Focuses on current information, presenting problems, and client insight in seeking and/or being referred to treatment

Elements of Discharge Plan

\-Referral source

\-Presenting problems/reasons for services

\-Tx goals, outcomes, and methods

\-Condition of client served at time of discharge

\-F/u recommendations (cont. of care/recovery support)

\-Signature/date and counselor credententials

SOAP Note

-Subjective

-Objective

-Assess

-Plan

Elements of Intervention Documentation

\-Client identifying information

\-Source of referral

\-Client placement information

\-Screening information

\-Informed consent and releases/ urine and breath

\-Intervention plan

\-Summary notes progress, goals, and objectives

\-Copy of services

\-Transfer and/or discharge summary

42 CFR Pt.2

Code of federal regulation for confidentiality

Confidentiality in areas of alcohol and substance abuse.

Records, Communication, Acknowledgment of a client in Tx

Treatment of Tobacco use

Bupropion and varenicline

Treatment of Alcohol

Naltrexone and disulfiram

ATRIUM - Addictions and Trauma Recovery Integration Model

12-session recovery model designed for groups as well as for individuals. Suggests that recovery groups are a starting point for healing and recovery. This model has been used in local prisons, AIDS programs, etc.

Formication

Sesation like insects crawling over the skin. Especially in chronic cocaine, meth, and users of other stimulants

Ranks highest for quitting

Quitting Tobacco

CADC

Screen clients, SUD assessment, create Tx plan. CANNOT diagnose mental disorders

AUDIT

Alcohol Use Disorders Identification Test

Scores ranging from 13-19 for a Woman fall into Zone III with the recommendation of simple advice plus brief counseling and continued monitoring.

When scoring, the gender of the client will aide in determining the recommendation. Zone recommendations are as follows:

Zone I: Brief education
Zone II: Brief intervention
Zone III: Brief intervention or referral to specialized treatment
Zone IV: Referral to specialized treatment

MAST

Michigan Alcohol Screening test. 25 Qs.

Types of SUD groups

-Psychoeducational

-Skills development

-Cognitive/beh support

-Support groups

-Interpersonal process groups

NIDA

National Institute on Drug Abuse. Est.1980

Adopted ASI

ASI

Addiction Severity Index by the NIDA

Instrument Validity

To assess what is the purpose of assessing

Instrument Reliability

How well the Instrument consistently gives accurate information

CSAT

Center for Substance Abuse Treatment

Minimum duration of IOT

90 days

Most effective screening tools

Center of Substance Abuse Treatment

Alcohol Dependence Scale

Addiction Severity Index

DSM-5 Sustained Remission

No criteria being met for 12 months or longer

Dual relationship

Unethical

Matrix Model

6-week treatment approach that takes place on an intensive outpatient basis

structured, multi-component behavioral treatment model that consists of evidence-based practices, including relapse prevention, family therapy, group therapy, psycho-education, and self-help, delivered in a sequential and clinically coordinated manner

SAMHSA

Substance Abuse and Mental Health Service Administration

HIPAA

Health Insurance Portability and Accountability Act

CBT

Views substance abuse as an issue of dependency and dependency as a learned behavior that can be modified

stages of recovery

1. Early recovery

2. Middle recovery

3. Late recovery or maintenance

Regression

Reverting to a prior developmental level

Age that is most susceptible to SUD

Adolescents are most vulnerable due to the developing brain among others

Countertransference

Defense mechanism emotional reaction to the subject, therapist transfers emotions to a person in therapy

Transference

A phenomenon within psychotherapy in which repetitions of old feelings, attitudes, desires, or fantasies that someone displaces are subconsciously projected onto a here-and-now person. 

Introjection

Internalizing ideas or voice of other people

Paradoxical Intervention

Prescribing the symptom the client wants to resolve, reverse psychology

designed to eliminate undesirable behavior by encouraging the undesirable behavio

Sedative hypnotic and sleep inducted drugs

CNS depressant

Component of ethical decision making

Clarify, evaluate, decide, implement, monitor/modify

Threshold of effect

Least amount of Substances needed to feel something

Therapeutic effect

How much of a drug you take to get the desired effect

Alcohol servings

5 drinks is a binge episode

Serving:

12oz beer

5oz wine

1\.5oz liquor

Marijuana

Schedule 1 substance

Outpatient

Individual and group counseling, duration 2 months to several years

Genes

Account for 40-60% of vulnerability to addiction

Types of SUD Tx approaches

1. group
2. family/individual
3. recovery paradigm


1. EBP

Ethics of SUD Tx

1. Competency in knowledge, culture, theoretical
2. Values
3. Client rights - Confidentiality, consents, etc.

Cultural

1. Cultural Competence
2. Cultural influence on behavior, SU, etc.
3. Substance Cultures


1. Gangs
2. Religion

4 spirits of MI

1. Partnership/collaboration

2. Acceptance/Autonomy

3. Compassion

4. Evocation - belief that resources and motivation for change are w/in the client

MI 5 principles

1. Ask open-ended Qs
2. Listen reflectively
3. Summarize
4. Affirm
5. Elicit Self-motivation

Types of treatment

w/drawal detoxification

outpatient

inpatient

medically assisted

Models of Treatment Plans

Medical

Psychological

Sociocultural

Biopsychosocial

Spiritual

5 levels of care

0\.5 early intervention

1 outpatient

2 outpatient/partial hospitalization

3 inpatient/residential

4 medically assisted

5 stages of SUD

Pre-contemplation

Contemplate

Action

Maintenance

Recovery/Relapse

DSM-5 Signs/Symptoms Criteria

Mild 2-3

Moderate 4-5

Severe - 6+

Naltrexone

What medication is used to treat Alcohol and Opioids

DSM 5 sustained remission

No criteria being met for 12 months or longer

group models

Psychoeducational

Cognitive Behavioral

Interpersonal

Support

Projection

Defense mechanism in which project undesirable feelings onto someone

Repression

Keep threatening thoughts from being conscious

Denial

Blocking external events from awareness

CBT

Brief and time limited, an average of 16 sessions, highly instructive, structured and directive

Outpatient duration

2 months to several years

GATE

Gather Information

Access supervision

Take responsible action

Extend the action

Drug tolerance

Decreased sensitivity to a drug over time develops after regular use. Develops as the body seeks homeostasis

Counseling

Collaborative process that includes methods that are sensitive to individual client characteristics

Observe, recognize, asses, and document client progress to evaluate the effectiveness and tx objectives

role of the clinician

Observe

Recognize

Assess

Document

Evaluate effectiveness

Therapeutic Alliance

Counselor and the client plays in helping achieve successful outcomes

Relationship or bond between therapist and client

Consensus between counselor and client regarding techniques/methods employed in treatment

Consensus between therapist and client regarding goals of treatment

Duration of methadone treatment

12 months of treatment is the minimum

elements of 12-step

Accessibility

Anonymity

Social support and mutual aid

Promotion of self-esteem and self-efficacy

Introspection and insight

Spiritual recovery

Advocacy to promote social and legislative remedies w/ respect to the issue of concern

Withdrawal Management

Considered short-term service 3-10 days

Duration & location depends on severity of intoxication

Evaluation

Stabilization

Fostering client’s entry into treatment

MAT

Medication Assisted Treatment

May be provided in an outpatient setting or an outpatient medication unit (pharmacy/physicians office)

Medications used for opioid addicition

Methadone

buprenorphine

naltrexone

Residential treatment duration

Duration can range from a couple of weeks to as much as 1 year

Medications used for SUD

Naltrexone

Disulfram

Acamprosate

Methadone

Buprenorphine/Suboxone

Assessment

In-depth evaluation that confirms presence of a problem, determines its severity, and specifies tx options for addressing the problem

Clinical evaluation

Interpret results of screening and assessment and integrate all available information to formulate a diagnostic impression and determine appropriate course of action

Assessment instruments

Standardized interviews

Structured interviews

Self-administered tests

What to do in a current presentation of suicide

If several factors are present, make an immediate referral for a more thorough evaluation

suicide risk assessment domains

Current presentation of suicidality

History

Risk management

Moral model

Model do not accept that there is any biological basis for addiction. Focuses on individual choices

Disease Model

Model that addiction is an illness

Genetic Model

Model that genetic predisposition is often a factor in dependency

Cultural model

Model recognizes that culture is strong determinant of obtaining substances

Blended model

Model that dependency is different for different individuals

SAMHSA 4 categories

1. MI less severe, SU less severe

2. MI more severe, SU less severe

3. MI less severe, SU more severe

4. MI more severe, SU more severe

ASI 6 problem domains

1. Medical status

2. Employment and support

3. alcohol and drug use

4. legal status

5. family and social status

6. psychiatric status

matrix model

6 week treatment IOT

Addresses stimulant abuse/ refers to neurobehavioral treatment