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| examples of progress notes for substance abuse: The Addiction Progress Notes Planner Arthur E. Jongsma, Jr., David J. Berghuis, 2015-03-20 Save hours of time-consuming paperwork The Addiction Progress Notes Planner, Fifth Edition provides prewritten session and patient presentation descriptions for each behavioral problem in the Addiction Treatment Planner, Fifth Edition. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes Organized around 44 behaviorally based presenting problems including depression, gambling, nicotine abuse/dependence, chronic pain, and eating disorders Features over 1,000 prewritten progress notes summarizing patient presentation, themes of session, and treatment delivered Provides an array of treatment approaches that correspond with the behavioral problems and DSM-5 diagnostic categories in The Addiction Treatment Planner, Fifth Edition Offers sample progress notes that conform to the latest ASAM guidelines and meet the requirements of most third-party payors and accrediting agencies, including CARF, TJC, COA, and the NCQA Incorporates new progress notes language consistent with Evidence-Based Treatment Interventions |
| examples of progress notes for substance abuse: The Addiction Progress Notes Planner Arthur E. Jongsma, Jr., David J. Berghuis, 2009-06-05 PracticePlanners: The Bestselling treatment planning system for mental health professionals The Addiction Progress Notes Planner, Third Edition contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Addiction Treatment Planner, Fourth Edition. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes Organized around 44 behaviorally based presenting problems, including depression,gambling, nicotine abuse/dependence, anxiety, and eating disorders Features over 1,000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered) Provides an array of treatment approaches that correspond with the behavioral problems and DSM-IV-TRTM diagnostic categories in The Addiction Treatment Planner, Fourth Edition Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA Presents new and updated information on the role of evidence-based practice in progress notes writing and the special status of progress notes under HIPAA |
| examples of progress notes for substance abuse: TIP 35: Enhancing Motivation for Change in Substance Use Disorder Treatment (Updated 2019) U.S. Department of Health and Human Services, 2019-11-19 Motivation is key to substance use behavior change. Counselors can support clients' movement toward positive changes in their substance use by identifying and enhancing motivation that already exists. Motivational approaches are based on the principles of person-centered counseling. Counselors' use of empathy, not authority and power, is key to enhancing clients' motivation to change. Clients are experts in their own recovery from SUDs. Counselors should engage them in collaborative partnerships. Ambivalence about change is normal. Resistance to change is an expression of ambivalence about change, not a client trait or characteristic. Confrontational approaches increase client resistance and discord in the counseling relationship. Motivational approaches explore ambivalence in a nonjudgmental and compassionate way. |
| examples of progress notes for substance abuse: The Counselor's Steps for Progress Notes Rhonda Sutton, 2015-06-21 Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation. |
| examples of progress notes for substance abuse: The Assessment and Treatment of Addiction Itai Danovitch, Larissa Mooney, 2018-11-15 Get a quick, expert overview of all types of addiction – from substance use disorders to behavioral addictions and more. This practical resource presents a focused summary of today's current knowledge on topics of interest to all health care professionals who work with those who suffer from this wide-ranging problem. It provides current, relevant information on emerging findings, best practices, and treatment challenges, covering a variety of assessment and treatment strategies and making it a one-stop resource for staying up to date in this critical area. - Discusses precision health in addiction; the latest trend of electronic cigarettes; state-of-the-art treatments for opioid use disorder and cannabis use disorder; best practices for chronic pain; prevention among adolescents; the role of physicians in the prescription drug epidemic; and the role of integrative interventions in addiction treatment. - Includes coverage of behavioral addictions such as internet, sex, and gambling; food addiction; PTSD and substance use disorders; preventing relapse; the neurobiology of addiction; and more. - Consolidates today's available information on this timely topic into one convenient resource. |
| examples of progress notes for substance abuse: Clinical Supervision and Professional Development of the Substance Abuse Counselor United States. Department of Health and Human Services, 2009 Clinical supervision (CS) is emerging as the crucible in which counselors acquire knowledge and skills for the substance abuse (SA) treatment profession, providing a bridge between the classroom and the clinic. Supervision is necessary in the SA treatment field to improve client care, develop the professionalism of clinical personnel, and maintain ethical standards. Contents of this report: (1) CS and Prof¿l. Develop. of the SA Counselor: Basic info. about CS in the SA treatment field; Presents the ¿how to¿ of CS.; (2) An Implementation Guide for Admin.; Will help admin. understand the benefits and rationale behind providing CS for their program¿s SA counselors. Provides tools for making the tasks assoc. with implementing a CS system easier. Illustrations. |
| examples of progress notes for substance abuse: The Psychotherapy Documentation Primer Donald E. Wiger, 2020-11-04 Everything you need to know to record client intake, treatment, and progress—incorporating the latest managed care, accrediting agency, and government regulations Paperwork and record keeping are day-to-day realities in your mental health practice. Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger group practices, inpatient facilities, and hospitals. The standard professionals and students have turned to for quick and easy, yet comprehensive, guidance to writing a wide range of mental health documents, the Fourth Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. Fully updated to include diagnostic criteria of the DSM-5, The Psychotherapy Documentation Primer, 4th Edition is designed to teach documental skills for the course of psychotherapy from the initial interview to the discharge. The documentation principles discussed in the text satisfy the often-rigid requirements of third-party insurance companies, regulating agencies, mental health licensing boards, and federal HIPAA regulations. More importantly, it provides students and professionals with the empirical and succinct documentation techniques and skills that will allow them to provide clear evidence of the effects of mental health treatment while also reducing the amount of their time spent on paperwork. |
| examples of progress notes for substance abuse: Motivational Enhancement Therapy Manual , 1992 |
| examples of progress notes for substance abuse: The Clinical Documentation Sourcebook Donald E. Wiger, 2010-02-02 All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file. |
| examples of progress notes for substance abuse: Brief Interventions and Brief Therapies for Substance Abuse , 2012 |
| examples of progress notes for substance abuse: The Adult Psychotherapy Progress Notes Planner Arthur E. Jongsma, Jr., David J. Berghuis, 2014-01-27 Save hours of time-consuming paperwork with the bestselling treatment planning system The Adult Psychotherapy Progress Notes Planner, Fifth Edition contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes Organized around 43 behaviorally based presenting problems, including depression, intimate relationship conflicts, chronic pain, anxiety, substance abuse, borderline personality, and more Features over 1,000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered) Provides an array of treatment approaches that correspond with the behavioral problems and DSM-5TM diagnostic categories in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA Identifies the latest evidence-based care treatments with treatment language following specific guidelines set by managed care and accrediting agencies |
| examples of progress notes for substance abuse: Case Conceptualization Len Sperry, Jon Sperry, 2020-05-27 Integrating recent research and developments in the field, this revised second edition introduces an easy-to-master strategy for developing and writing culturally sensitive case conceptualizations and treatment plans. Concrete guidelines and updated case material are provided for developing conceptualizations for the five most common therapy models: Cognitive-Behavioral Therapy (CBT), Psychodynamic, Biopsychosocial, Adlerian, and Acceptance and Commitment Therapy. The chapters also include specific exercises and activities for mastering case conceptualization and related competencies and skills. Also new to this edition is a chapter on couple and family case conceptualizations, and an emphasis throughout on trauma. Practitioners, as well as graduate students in counseling and in clinical psychology, will gain the essential skills and knowledge they need to master case conceptualizations. |
| examples of progress notes for substance abuse: Addiction Treatment Matching David R. Gastfriend, 2004 Also appearing as Journal of Addictive Diseases, v. 22, supplement number 1 (2003), this book contains ten research studies by experts in mental health and addiction services. It specifically examines the ASAM Patient Placement Criteria, with an eye toward its effect on health plans, treatment programs, and patients. The editor is a medical doctor affiliated with the addiction research program at Massachusetts General Hospital and a professor at Harvard Medical School. Annotation : 2004 Book News, Inc., Portland, OR (booknews.com). |
| examples of progress notes for substance abuse: Improving the Quality of Health Care for Mental and Substance-Use Conditions Institute of Medicine, Board on Health Care Services, Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, 2006-03-29 Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are seriousâ€for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substanceâ€use conditions will benefit from this guide to achieving better care. |
| examples of progress notes for substance abuse: The Addiction Counselor's Documentation Sourcebook James R. Finley, Brenda S. Lenz, 2005-01-26 All of the requisite forms addiction treatment professionals need—a crucial time-saver in today's healthcare system Treating addiction in today's healthcare environment means that mental health professionals must manage an imposing amount of paperwork. Government and private grant funding, insurance and benefits programs, regulatory compliance, and the need for data on treatment effectiveness (evidence-based treatment) all require proper documentation. If these forms are missing, the results can range from bureaucratic headaches to problems serious enough to close a practice. Now fully updated and revised, The Addiction Counselor's Documentation Sourcebook: The Complete Paperwork Resource for Treating Clients with Addictions, Second Edition provides the most useful and current forms for accurate and comprehensive documentation and record keeping. These ready-to-use forms will save you and your practice hours that would otherwise be spent creating and collating them, freeing you to devote more energy to the important matters of treatment. A companion CD-ROM includes all documents in Word? format so you can customize them according to the unique needs of your practice. Covering every aspect of mental health practice for addiction treatment, this fully revised Second Edition also includes: Critical forms updated to help providers achieve HIPAA, JCAHO, and CARF compliance Unique handouts, exercises, and facilitator guides for use in individual and group therapy A comprehensive CD-ROM featuring all forms in Word format, as well as PowerPoint slideshows for every psychoeducational presentation in the book The Addiction Counselor's Documentation Sourcebook, Second Edition is an essential timesaving resource that allows any professional practicing or working in the field of addiction treatment the freedom to give more of their time and energy to the people they serve. |
| examples of progress notes for substance abuse: Overcoming Your Alcohol or Drug Problem Dennis C. Daley, G. Alan Marlatt, 2006-06-15 A substance use problem exists when one experiences any type of difficulty related to using alcohol, tobacco, or other drugs including illicit street drugs or prescribed drugs such as painkillers or tranquilizers. The difficulty can be in any area of life; medical or physical, psychological, family, interpersonal, social, academic, occupational, legal, financial, or spiritual. This expanded new edition of the successful Graywind Publications title provides the reader with practical information and skills to help them understand and change a drug or alcohol problem. Designed to be used in conjunction with therapy or counseling, it focuses on special issues involved in stopping substance use and in changing behaviors or aspects of one's lifestyle that keep the substance use problem active. The information presented is derived from a wealth of research studies, and discusses the most effective recovery strategies from the examination of cognitive-behavoral treatment. TreatmentsThatWorkTM represents the gold standard of behavioral healthcare interventions! · All programs have been rigorously tested in clinical trials and are backed by years of research · A prestigious scientific advisory board, led by series Editor-In-Chief David H. Barlow, reviews and evaluates each intervention to ensure that it meets the highest standard of evidence so you can be confident that you are using the most effective treatment available to date · Our books are reliable and effective and make it easy for you to provide your clients with the best care available · Our corresponding workbooks contain psychoeducational information, forms and worksheets, and homework assignments to keep clients engaged and motivated · A companion website (www.oup.com/us/ttw) offers downloadable clinical tools and helpful resources · Continuing Education (CE) Credits are now available on select titles in collaboration with PsychoEducational Resources, Inc. (PER) |
| examples of progress notes for substance abuse: Addictions Barbara S. McCrady, Elizabeth E. Epstein, 1999-04-15 Today, alcohol and other drug abuse scientists have access to a broad array of clinical resources that integrate a commonsensical approach to addiction treatment with science. Addictions: A Comprehensive Guidebook is a superb example of one such resource. Here, in one volume, is both practical and scholarly information for alcohol and drug abuse specialists, primary care providers, clinicians, policy-makers, and others involved in programs that are geared to help those who abuse or are dependent on alcohol and other drugs. Its scope is a testament to how far drug abuse scientists and practitioners have come in defining what they do and to how they are able to do it effectively through a growing body of scientific behavioral research. Addictions is organized into seven parts that range from the prevalence of certain addictions to their identification and treatment to the social effects of these addictions. In fact, this volume contains nearly all of the basic information a professional or graduate student needs to learn about or treat substance abuse. |
| examples of progress notes for substance abuse: Behavioral Couples Therapy for Alcoholism and Drug Abuse Timothy J. O'Farrell, William Fals-Stewart, 2012-03-12 This eminently practical guide presents an empirically supported approach for treating people with substance abuse problems and their spouses or domestic partners. Behavioral couples therapy (BCT) explicitly focuses on both substance use and relationship issues, and is readily compatible with 12-step approaches. In a convenient large-size format, the book provides all the materials needed to introduce BCT; implement a recovery contract to support abstinence; work with clients to increase positive activities, improve communication, and reduce relapse risks; and deal with special treatment challenges. Appendices include a session-by-session treatment manual and 70 reproducible checklists, forms, and client education posters. |
| examples of progress notes for substance abuse: Developing Clinical Skills for Substance Abuse Counseling Daniel L. Yalisove, 2010 This skill-building primer provides a framework for understanding substance abuse and teaches the basic concepts and skills necessary for effective counseling of clients with substance use disorders. In Part I, Dr. Yalisove discusses counselor roles and the fundamental principles of substance abuse counseling. He then provides a synopsis of several key substance abuse theories as well as his own Building Session Goals and Strategies method and the Eight Stage Process of Counseling approach, all of which are practical, compatible means for learning and mastering clinical counseling skills. Part II illustrates applications of the tenets of these approaches in clinical situations-from beginning counseling sessions through termination-using experiential exercises, role-plays, and clinical scenario examples. Chapters on group work, counseling clients with dual disorders, family counseling, and working with diverse client populations follow. A helpful chapter on creating client treatment plans and writing clinical reports rounds out the book. Dr. Yalisove's clear and concise writing style and his practical approach to developing critical thinking and counseling skills makes this an ideal supplemental text for addictions courses.--Amazon.com. |
| examples of progress notes for substance abuse: Clinical Guide to Alcohol Treatment Robert J. Meyers, Jane Ellen Smith, 1995-08-04 This book is the first complete guide to implementing the Community Reinforcement Approach (CRA), an empirically based, highly effective cognitive-behavioral program for treating alcohol problems. CRA acknowledges the powerful role of environmental contingencies in encouraging or discouraging drinking, and attempts to rearrange these contingencies so that a non-drinking lifestyle is more rewarding than a drinking one. Unique in its breadth, the approach utilizes social, recreational, familial, and vocational strategies to aid clients in the recovery process. This authoritative manual is a hands-on guide to applying these therapeutic procedures. The authors present a step-by-step guide to each component of the treatment plan, many of which have been shown to be effective forms of treatment in themselves. Topics include behavioral skills training, social and recreational counseling, marital therapy, motivational enhancement, job counseling, and relapse prevention. Each chapter provides detailed instructions for conducting a procedure, describes what difficulties to expect, and presents strategies for overcoming them. Sample dialogues between clients and therapists, annotated by the authors, further illuminate the treatment process. The book concludes with a chapter that both addresses the common mistakes made when implementing CRA, and emphasizes the flexibility and benefits of this total treatment plan. This book is an invaluable resource for a wide range of practitioners including psychologists, psychiatrists, substance abuse counselors, and social workers. |
| examples of progress notes for substance abuse: Treatment Services for Adolescent Substance Abusers Alfred S. Friedman, George M. Beschner, 1998-04 Highlights and integrates what is known about adolescent substance abusers, their drug and drug-related problems, the programs that serve them, and the treatment methods and approaches that have proven to be most effective. It is intended to serve as a guide for those who are currently involved or who plan to become involved in the treatment of adolescent substance abusers. Covers: family factors; referral and diagnosis; individualized treatment; counseling; structural family therapy; group therapy; treatment in schools; supportive life skills; treatment in a therapeutic community, and much more. |
| examples of progress notes for substance abuse: Psychosocial Interventions for Mental and Substance Use Disorders Institute of Medicine, Board on Health Sciences Policy, Committee on Developing Evidence-Based Standards for Psychosocial Interventions for Mental Disorders, 2015-09-18 Mental health and substance use disorders affect approximately 20 percent of Americans and are associated with significant morbidity and mortality. Although a wide range of evidence-based psychosocial interventions are currently in use, most consumers of mental health care find it difficult to know whether they are receiving high-quality care. Although the current evidence base for the effects of psychosocial interventions is sizable, subsequent steps in the process of bringing a psychosocial intervention into routine clinical care are less well defined. Psychosocial Interventions for Mental and Substance Use Disorders details the reasons for the gap between what is known to be effective and current practice and offers recommendations for how best to address this gap by applying a framework that can be used to establish standards for psychosocial interventions. The framework described in Psychosocial Interventions for Mental and Substance Use Disorders can be used to chart a path toward the ultimate goal of improving the outcomes. The framework highlights the need to (1) support research to strengthen the evidence base on the efficacy and effectiveness of psychosocial interventions; (2) based on this evidence, identify the key elements that drive an intervention's effect; (3) conduct systematic reviews to inform clinical guidelines that incorporate these key elements; (4) using the findings of these systematic reviews, develop quality measures - measures of the structure, process, and outcomes of interventions; and (5) establish methods for successfully implementing and sustaining these interventions in regular practice including the training of providers of these interventions. The recommendations offered in this report are intended to assist policy makers, health care organizations, and payers that are organizing and overseeing the provision of care for mental health and substance use disorders while navigating a new health care landscape. The recommendations also target providers, professional societies, funding agencies, consumers, and researchers, all of whom have a stake in ensuring that evidence-based, high-quality care is provided to individuals receiving mental health and substance use services. |
| examples of progress notes for substance abuse: Facing Addiction in America Office of the Surgeon General, U.s. Department of Health and Human Services, 2017-08-15 All across the United States, individuals, families, communities, and health care systems are struggling to cope with substance use, misuse, and substance use disorders. Substance misuse and substance use disorders have devastating effects, disrupt the future plans of too many young people, and all too often, end lives prematurely and tragically. Substance misuse is a major public health challenge and a priority for our nation to address. The effects of substance use are cumulative and costly for our society, placing burdens on workplaces, the health care system, families, states, and communities. The Report discusses opportunities to bring substance use disorder treatment and mainstream health care systems into alignment so that they can address a person's overall health, rather than a substance misuse or a physical health condition alone or in isolation. It also provides suggestions and recommendations for action that everyone-individuals, families, community leaders, law enforcement, health care professionals, policymakers, and researchers-can take to prevent substance misuse and reduce its consequences. |
| examples of progress notes for substance abuse: The Early Childhood Education Intervention Treatment Planner David J. Berghuis, Julie A. Winkelstern, 2006-04-20 The Early Childhood Education Intervention Treatment Planner provides all the elements necessaryto quickly and easily develop formal education treatment plans that take the educational professional a step further past the writing of goals for Individualized Education Plans (IEPs) as well as mental health treatment plans. The educational treatment plan process assists the professional in identifying interventions and communicating to others the specific method, means, format, and/or creative experience by which the student will be assisted in attaining IEP goals. Critical tool for treating the most common problems encountered in treating children ages 3-6 Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized educational treatment plans Organized around 27 main presenting problems, including autism, cultural and language issues, depression, eating and elimination concerns, cognitive and neurological impairment, oppositional behavior, school entry readiness, and others Over 1,000 well-crafted, clear statements describe the behavioral manifestations of each relational problem, long-term goals, short-term objectives, and educational interchange Easy-to-use reference format helps locate educational treatment plan components by disability Includes a sample treatment plan that conforms to the requirements of most third-party payors and accrediting agencies (including HCFA, JCAHO, and NCQA) |
| examples of progress notes for substance abuse: Addiction Counseling Competencies , 1998 |
| examples of progress notes for substance abuse: Alcohol and Other Drug Screening of Hospitalized Trauma Patients Peter O. Rostenberg, 1995 |
| examples of progress notes for substance abuse: Results from the ... National Survey on Drug Use and Health National Survey on Drug Use and Health (U.S.), 2002 |
| examples of progress notes for substance abuse: The Complete Adult Psychotherapy Treatment Planner David J. Berghuis, L. Mark Peterson, 2006-07-28 The Complete Adult Psychotherapy Treatment Planner, Fourth Edition provides all the elements necessary to quickly and easily develop formal treatment plans that satisfy the demands of HMOs, managed care companies, third-party payors, and state and federal agencies. New edition features: Empirically supported, evidence-based treatment interventions Organized around 43 main presenting problems, including anger management, chemical dependence, depression, financial stress, low self-esteem, and Obsessive-Compulsive Disorder Over 1,000 prewritten treatment goals, objectives, and interventions - plus space to record your own treatment plan options Easy-to-use reference format helps locate treatment plan components by behavioral problem Designed to correspond with the The Adult Psychotherapy Progress Notes Planner, Third Edition and the Adult Psychotherapy Homework Planner, Second Edition Includes a sample treatment plan that conforms to the requirements of most third-party payors and accrediting agencies (including CARF, JCAHO, and NCQA). |
| examples of progress notes for substance abuse: The Therapeutic Community George De Leon, PhD, 2000-04-15 This volume provides a comprehensive review of the essentials of the Therapeutic Community (TC) theory and its practical whole person approach to the treatment of substance abuse disorders and related problems. Part I outlines the perspective of the traditional views of the substance abuse disorder, the substance abuser, and the basic components of this approach. Part II explains the organizational structure of the TC, its work components, and the role of residents and staff. The chapters in Part III describe the essential activities of TC life that relate most directly to the recovery process and the goals of rehabilitation. The final part outlines how individuals change in the TC behaviorally, cognitively, and emotionally. This is an invaluable resource for all addictions professionals and students. |
| examples of progress notes for substance abuse: Screening and Assessing Adolescents for Substance Use Disorders Ken C. Winters, 2000 Presents information on identifying, screening, and assessing adolescents who use substances. This report focuses on the most current procedures and instruments for detecting substance abuse among adolescents, conducting comprehensive assessments, and beginning treatment planning. Presents appropriate strategies and guidelines for screening and assessment. Explains legal issues concerning Federal and State confidentiality laws. Provides guidance for screening and assessing adolescents in juvenile justice settings. Summarizes instruments to screen and assess adolescents for substance and general functioning domains. |
| examples of progress notes for substance abuse: Documentation Manual for Occupational Therapy Crystal Gateley, 2024-06-01 The best-selling, newly updated occupational therapy textbook Documentation Manual for Occupational Therapy, Fifth Edition, is made for students and early-career practitioners learning the critical skill of documentation. The workbook format offers students ample opportunities to practice writing occupation-based problem statements and goals, intervention plans, SOAP notes, and other forms of documentation. The Fifth Edition has also been updated to reflect changes in the American Occupational Therapy Association’s Occupational Therapy Practice Framework: Domain and Process, Fourth Edition. What’s included in Documentation Manual for Occupational Therapy: • Numerous worksheets for students to practice individual skills with suggested answers provided in the Appendix • Updated information on coding, billing, and reimbursement to reflect recent Medicare changes, particularly in post–acute care settings • Examples from a variety of contemporary occupational therapy practice settings Included with the text are online supplemental materials for faculty use in the classroom. Instructors in educational settings can visit the site for an Instructor’s Manual with resources to develop an entire course on professional documentation or to use the textbook across several courses. One of the most critical skills that occupational therapy practitioners must learn is effective documentation to guide client care, communicate with colleagues, and maximize reimbursement. The newly updated and expanded Documentation Manual for Occupational Therapy, Fifth Edition, will help students master their documentation skills before they ever step foot into practice. |
| examples of progress notes for substance abuse: Adolescent Psychotherapy Homework Planner Arthur E. Jongsma, Jr., L. Mark Peterson, William P. McInnis, Timothy J. Bruce, 2024-01-04 Evidence-based and effective clinical homework for adolescent clients and their caregivers In the newly updated sixth edition of The Adolescent Psychotherapy Homework Planner, a team of distinguished practitioners delivers a time-saving and hands-on practice tool designed to offer clients valuable homework assignments that will further their treatment goals for a wide variety of presenting problems. The Homework Planner addresses common and less-common disorders—including anxiety, depression, substance use, eating, and panic—allowing the client to work between sessions on issues that are the focus of therapy. This book provides evidence-based homework assignments that track the psychotherapeutic interventions suggested by the fifth edition of The Adolescent Psychotherapy Treatment Planner. They are easily photocopied, and a digital version is provided online for the therapist who would prefer to access them with a word processor. The Homework Planner also offers: Cross-referenced lists of suggested presenting problems for which each assignment may be appropriate (beyond its primary designation) Several brand-new assignments, as well as adapted assignments that have been shortened or modified to make them more adolescent-client-friendly Homework assignments for the parents of adolescents in treatment, assignments for the adolescents themselves, and assignments for parents and adolescents to complete together An essential and practical tool for therapists and practitioners treating adolescents, The Adolescent Psychotherapy Homework Planner, Sixth Edition will benefit social workers, psychologists, psychiatrists, and other clinicians seeking efficient and effective homework tools for their clients. |
| examples of progress notes for substance abuse: A Cognitive-behavioral Approach Kathleen M. Carroll, 2000 |
| examples of progress notes for substance abuse: The Addiction Treatment Planner Robert R. Perkinson, David J. Berghuis, 2009-04-03 This timesaving resource features: Treatment plan components for 44 behaviorally based presenting problems Over 1,000 prewritten treatment goals, objectives, and interventions-plus space to record your own treatment plan options A step-by-step guide to writing treatment plans that conform to the latest ASAM requirements and meet the requirements of most accrediting bodies, insurance companies, and third-party payors Includes new Evidence-Based Practice Interventions as required by many public funding sources and private insurers The Addiction Treatment Planner, Fourth Edition provides all the elements necessary to quickly and easily develop formal treatment plans that satisfy the demands of HMOs, managed care companies, third-party payors, and state and federal agencies. New edition features empirically supported, evidence-based treatment interventions New treatment planning language based on the mandates of the American Society of Addiction Medicine (ASAM) Organized around 44 main presenting problems, including Adhd, borderline traits, eating disorders, gambling, impulsivity, psychosis, social anxiety, and substance abuse Over 1,000 prewritten treatment goals, objectives, and interventions-plus space to record your own treatment plan options Easy-to-use reference format helps locate treatment plan components by behavioral problem Designed to correspond with The Addiction Progress Notes Planner, Third Edition and Addiction Treatment Homework Planner, Fourth Edition Includes a sample treatment plan that conforms to the requirements of most third-party payors and accrediting agencies (including CARF, The Joint Commission (TJC), COA, and the NCQA) Additional resources in the PracticePlanners series: Progress Notes Planners contain complete, prewritten progress notes for each presenting problem in the companion Treatment Planners. Homework Planners feature behaviorally based, ready-to-use assignments to speed treatment and keep clients engaged between sessions. |
| examples of progress notes for substance abuse: Empirically Based Play Interventions for Children Linda A. Reddy, Tara M. Files-Hall, Dr Charles E Schaefer, 2016 This updated edition presents new research that establishes the effectiveness of play therapy in promoting healthy development in children with emotional or behavioral difficulties. Innovative interventions are presented in detail with vivid case examples to illustrate their implementation in clinical practice. |
| examples of progress notes for substance abuse: What Every Therapist Needs to Know Michael Karson, 2018-06-20 With the ubiquity of knowledge on too many topics relevant to psychotherapy and life problems, it is difficult for therapists to muddle through and stay up-to-date. Therapists often have to choose between braving a bewildering onslaught of information and wishfully disregarding all that’s out there. What Every Therapist Needs to Know answers for therapists the practical, humble question, “What do I need to know about a topic to practice competently?” This book provides an engaging overview on the topics that working clinicians need to know about, while drawing parallels between the therapist’s professional growth and the patient’s personal growth. Foundational knowledge on learning, life, and psychology segues into the therapy topics of conflict resolution, the working alliance, the therapeutic frame, technique, and feedback. What Every Therapist Needs to Know emphasizes the application of psychological theories to the therapy itself and not just to the patient’s life. |
| examples of progress notes for substance abuse: Crossing the Quality Chasm Institute of Medicine, Committee on Quality of Health Care in America, 2001-07-19 Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change. |
| examples of progress notes for substance abuse: Journal of Rehabilitation Research and Development , 2010 |
| examples of progress notes for substance abuse: 2017 Catalog of Federal Domestic Assistance United States. Congress. Senate. Office of Management and Budget. Executive Office of the President, 2017 Identifies and describes specific government assistance opportunities such as loans, grants, counseling, and procurement contracts available under many agencies and programs. |
| examples of progress notes for substance abuse: Group Therapy for Substance Use Disorders Linda Carter Sobell, Mark B. Sobell, 2011-06-22 This authoritative book presents a groundbreaking evidence-based approach to conducting therapy groups for persons with substance use disorders. The approach integrates cognitive-behavioral, motivational interviewing, and relapse prevention techniques, while capitalizing on the power of group processes. Clinicians are provided with a detailed intervention framework and clear-cut strategies for helping clients to set and meet their own treatment goals. More than two dozen ready-to-use reproducible assessment tools, handouts, homework exercises, and session outlines are supplied in a convenient large-size format. |
Sample Substance Abuse Intensive Outpatient Progress Note …
Content Documentation of Substance Use Disorders: Progress Notes Below is a fictional example of a progress note in the SOAP (Subjective, Objective, Assessment, Plan) format. For the purposes …
SUD COUNSELOR HANDBOOK WITH DOCUMENTATION …
The County of Orange provides Substance Use Disorder (SUD) services to adolescents and adults who have a substance use disorder.
Sample Substance Abuse Intensive Outpatient Progress Note Copy
Sample Substance Abuse Intensive Outpatient Progress … substance use disorders. Substance misuse and substance use disorders have devastating effects, disrupt the future plans of too …
EXAMPLE S.O.A.P. NOTE - United Nations Office on Drugs and Crime
♦ Example: 20 minutes late to group session, slouched in chair, head down, later expressed interest in topic. A = Assessment of the situation, the session, and the client, regardless of how obvious it …
Peer Support Documentation - Best Practices and Strategies 1.27
Record topics discussed, goals in progress or status of tasks, successes or challenges, concerns or examples of what is going well. Plan – What are the next steps? Record any actions to be taken …
SAMPLE SUD TREATMENT PROGRESS NOTE - optumsandiego.com
IT IS NOT THE ONLY WAY TO DOCUMENT AN INDIVIDUAL PROGRESS NOTE. ALL PROGRESS NOTES NEED TO BE INDIVIDUALIZED AND SPECIFIC TO THE CLIENT'S PARTICIPATION IN …
Specialty Substance Use Disorder (SUD) System Documentation …
Importantly, these are only examples and there are various acceptable ways to provide good documentation to justify medical necessity for care, but the important thing is to include relevant …
SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS …
6 Apr 2016 · Patient statements that capture the theme of the session. Brief statements as quoted by the patient may be used, as well as paraphrased summaries. Observable data or information …
Susan Smith - Between Sessions
Assessment: Depressed mood with substance abuse. Client is under a lot of situational stress with limited emotional support. When this therapist brought up the possibility of taking anti …
Treatment Planning for Substance Use Disorders
•Treatment plans should be paired with thorough progress notes, addressing what has been accomplished during sessions, while incorporating the goals and objectives of the treatment plan.
Intake, Referral, Discharge, and Aftercare Planning - Thunderbird
As of June 2015, the National Native Addictions Partnership Foundation (NNAPF) changed its operating name to the Thunderbird Partnership Foundation, a division of NNAPF Inc. For more …
How to Develop Treatment Plans that Make Sense to Clients: …
27 Oct 2014 · Examples: By six months, “develop awareness of cognitive deficits” and utilization of cognitive rehabilitation resources”; “Client will reduce the frequency of distorted, negative …
ASAM Criteria Treatment Planning Template
progress and inform clinical decision-making, including updates to the treatment plan and determining when the patient should transition to a more or less intensive level of care.
SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS …
5 Sep 2017 · Please select the type of progress note. If a group note is selected, the number of counselors present in the group and the number of patients in the group are required.
Examples Of Progress Notes For Substance Abuse Full PDF
Progress Notes For Substance Abuse full book , it can give you a taste of the authors writing style.Subscription Services Platforms like Kindle Unlimited or Scribd offer subscription-based …
Individualized Substance Abuse Group Therapy Note Sample
Group Type: The focus of today’s group was the subject of sobriety management. Group members were first encouraged to examine the ways substance abuse has adversely effected their lives. …
Clinical Evaluation: Treatment Planning Goals and Objectives
addresses the identified substance use disorder(s), as well as issues related to treatment progress, including relationships with family and significant others, employment, education, spirituality, …
D: Process group met for 1.5 hrs. The group topic was “Emotional …
examples of common triggers relative to addiction. The group then discussed different emotional and physical triggers that have always lead them back to a lifestyle of drugs
Documentation of Substance Use Disorders: Progress Notes
Below is a fictional example of a progress note in the SOAP (Subjective, Objective, Assessment, Plan) format. For the purposes of this sample progress note, the focus is on the content of the progress note, rather than the format.
Sample Substance Abuse Intensive Outpatient Progress Note …
Content Documentation of Substance Use Disorders: Progress Notes Below is a fictional example of a progress note in the SOAP (Subjective, Objective, Assessment, Plan) format. For the purposes of this sample progress note, the focus is on the content of the progress note, rather than the format.
SUD COUNSELOR HANDBOOK WITH DOCUMENTATION GUIDELINES VERSION …
The County of Orange provides Substance Use Disorder (SUD) services to adolescents and adults who have a substance use disorder.
Sample Substance Abuse Intensive Outpatient Progress Note Copy
Sample Substance Abuse Intensive Outpatient Progress … substance use disorders. Substance misuse and substance use disorders have devastating effects, disrupt the future plans of too many young people, and all too often, end lives prematurely and tragically.
EXAMPLE S.O.A.P. NOTE - United Nations Office on Drugs and Crime
♦ Example: 20 minutes late to group session, slouched in chair, head down, later expressed interest in topic. A = Assessment of the situation, the session, and the client, regardless of how obvious it might be based on the subjective and/or objective statements.
Peer Support Documentation - Best Practices and Strategies 1.27
Record topics discussed, goals in progress or status of tasks, successes or challenges, concerns or examples of what is going well. Plan – What are the next steps? Record any actions to be taken based on the discussion. Next meeting – When is the next meeting or visit with the family?
SAMPLE SUD TREATMENT PROGRESS NOTE - optumsandiego.com
IT IS NOT THE ONLY WAY TO DOCUMENT AN INDIVIDUAL PROGRESS NOTE. ALL PROGRESS NOTES NEED TO BE INDIVIDUALIZED AND SPECIFIC TO THE CLIENT'S PARTICIPATION IN TREATMENT.
Specialty Substance Use Disorder (SUD) System Documentation Examples
Importantly, these are only examples and there are various acceptable ways to provide good documentation to justify medical necessity for care, but the important thing is to include relevant clinical information and rationale for providing that level …
SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS …
6 Apr 2016 · Patient statements that capture the theme of the session. Brief statements as quoted by the patient may be used, as well as paraphrased summaries. Observable data or information supporting the subjective statement.
Susan Smith - Between Sessions
Assessment: Depressed mood with substance abuse. Client is under a lot of situational stress with limited emotional support. When this therapist brought up the possibility of taking anti-depressant medication, he said he would consider it. Plan: Give client psychiatric referral for medication evaluation. Advise DBT skills to aid coping.
Treatment Planning for Substance Use Disorders
•Treatment plans should be paired with thorough progress notes, addressing what has been accomplished during sessions, while incorporating the goals and objectives of the treatment plan.
Intake, Referral, Discharge, and Aftercare Planning - Thunderbird
As of June 2015, the National Native Addictions Partnership Foundation (NNAPF) changed its operating name to the Thunderbird Partnership Foundation, a division of NNAPF Inc. For more information, visit www.thunderbirdpf.org.
How to Develop Treatment Plans that Make Sense to Clients: …
27 Oct 2014 · Examples: By six months, “develop awareness of cognitive deficits” and utilization of cognitive rehabilitation resources”; “Client will reduce the frequency of distorted, negative thoughts, use reframing
ASAM Criteria Treatment Planning Template
progress and inform clinical decision-making, including updates to the treatment plan and determining when the patient should transition to a more or less intensive level of care.
SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS …
5 Sep 2017 · Please select the type of progress note. If a group note is selected, the number of counselors present in the group and the number of patients in the group are required.
Examples Of Progress Notes For Substance Abuse Full PDF
Progress Notes For Substance Abuse full book , it can give you a taste of the authors writing style.Subscription Services Platforms like Kindle Unlimited or Scribd offer subscription-based access to a wide range of Examples Of Progress Notes For Substance Abuse eBooks, including some popular titles. Find Examples Of Progress Notes For Substance ...
Individualized Substance Abuse Group Therapy Note Sample
Group Type: The focus of today’s group was the subject of sobriety management. Group members were first encouraged to examine the ways substance abuse has adversely effected their lives. Group members were then directed to share and explore methods and strategies for remaining sober in the outpatient setting.
Clinical Evaluation: Treatment Planning Goals and Objectives
addresses the identified substance use disorder(s), as well as issues related to treatment progress, including relationships with family and significant others, employment, education, spirituality, health concerns, and legal needs.
D: Process group met for 1.5 hrs. The group topic was “Emotional …
examples of common triggers relative to addiction. The group then discussed different emotional and physical triggers that have always lead them back to a lifestyle of drugs
