Assessment
Why the patient is seeking treatment and what needs to be worked on while at BrightView
What is the presenting problem?
These are identified in the assessment and direct course of treatment
What are the recommendations?
Recent and history of use, recent and history of withdrawal symptoms
What is needed for Dimension 1?
Questions 11 and 12 need to match the first 10
What are the current and lifetime risk levels?
Final signature by independently licensed staff
Names, ages, relationships, and dynamics that pertain to support or triggers of substance use
What is the information needed in who lives with the patient?
Summary of collaboration and how the goals/problems not being worked on currently are being managed
Physical health, medical problems, and physical activity or nutrition concerns, pregnancy status and patient's perception of their health.
What is dimension 2?
Patient has recent substance use and recent SI, patient is of moderate risk so this is needed.
What is a safety plan?
Rostered for group, welcome group, assigned a counselor, first 2-4 weeks of appointments
What to do on day 2?
Family supports, peer supports, and why
Who is the patient's primary support system?
Relevant, achievable, timely, specific, and measurable including risk and\or protective factors
What are SMART goals?
What motivates the patient to seek treatment, their readiness and interest in changing, patient's awareness of the connection between substance use and negative experiences, and whether the patient has any concerns about their ability to participate in services.
What is dimension 4?
Patient is anything but zero risk to self or others so this is needed
What is an intervention?
Case management assessment, relapse prevention plan, message board current, rostered for group
MH, trauma, nicotine, transportation, housing, employment, and education
What are the necessary recommendations that need addressed in the assessment?
Date, progress, revisions, and why?
What goes in the narrative boxes under the goals and interventions?
Concerns about continued substance use or other symptoms related to SUD diagnosis or mental health diagnosis, or potential relapse of such symptoms without appropriate intervention, relapse prevention needs
What is dimension 5?
Summary of risk to self, summary of risk to others, and how this was able to be determined.
What is the risk assessment summary narrative?
Should be in the goal box, in their words, and reflective of their understanding of the goal
What is the patient quote?
What is needed to determine severity of substance use history?
Needed for the ITP to be valid
What is the patient signature on signature page?
Patient's living situation, and the people, places, and things in their environment that may impact recovery, risk factors and protective factors.
What is dimension 6?
Before leaving the building during day 1, as needed, and when the PHQ-9 score is 10 or higher.
When does an RA HAVE to be completed?
60 scheduled weekly for first 90 days and the explanation needed as to why 50 wasn't provided
What are the clinical minutes for OTP patients?