solve what treatment-specific information should be in the assessment

by Roger Greenholt Published 3 years ago Updated 2 years ago

Why do we need to assess the quality of treatment?

On the clinical side, treatment providers need instruments with which to assess the quality of treatment provision, as well as the progress of their clients during treatment. Their motivation is the same as that among researchers: Such instruments are seen as essential elements in the effort to improve clinical care.

What should be included in therapy assessment documentation?

In addition, your therapy assessment documentation should include a summary of the patient’s ability (or difficulty) in performing a specific task. Relating the treatment back to a functional goal will round out an excellent assessment.

When should I include an assessment in my documentation?

Most commonly, you’ll include an assessment when completing daily notes, documenting progress notes, or writing an evaluation. But no matter the occasion, the assessment component can become the most time-consuming portion of your documentation. Learning how to write efficient, effective notes early on will save you precious time.

How do we decide if a treatment is even needed?

First, we need to determine if a treatment is even needed. By having a clear accounting of the person’s symptoms and how they affect daily functioning, we can decide to what extent the individual is adversely affected.

What is an assessment for treatment?

Assessment is the process of obtaining information about the patient's drug use and how it is affecting his or her life. It is an essential part of treatment and care for people who use drugs.

What makes a treatment effective?

3. Effective Treatment Attends to Multiple Needs of the Individual, not just his or her drug use: To be effective, treatment must address the individual's drug use and any associated medical, psychological, social, vocational, and legal problems.

How can existing client assessment data be useful in effective treatment planning?

Screening and assessment data provide information that is integrated by the clinician and the client in the treatment planning process. Screening and assessment data also are useful in establishing a client's baseline of signs, symptoms, and behaviors that can then be used to assess progress.

What is the most effective treatment for addiction?

Some of the most strongly supported include: Cognitive-behavioral therapy. CBT can help addicted patients overcome substance abuse by teaching them to recognize and avoid destructive thoughts and behaviors.

How do we know if treatment has been successful discuss three different ways that the success of therapy can be assessed?

Ways of Assessing Effectiveness. The effectiveness of a particular therapeutic approach can be assessed in three ways: client testimonials, providers' perceptions, and empirical research.

What is an evidence based treatment?

Evidence-based treatment (EBT) refers to treatment that is backed by scientific evidence. That is, studies have been conducted and extensive research has been documented on a particular treatment, and it has proven to be successful.

What information is important to document in a treatment plan?

A treatment plan will include the patient or client's personal information, the diagnosis (or diagnoses, as is often the case with mental illness), a general outline of the treatment prescribed, and space to measure outcomes as the client progresses through treatment.

How do you write a treatment summary?

How do you write a treatment goal?

Treatment plans usually follow a simple format and typically include the following information:The patient's personal information, psychological history and demographics.A diagnosis of the current mental health problem.High-priority treatment goals.Measurable objectives.A timeline for treatment progress.More items...•

How do you develop a treatment plan for substance abuse?

Treatment plans should consider how substance abuse impacts all aspects of your life, including your mental, physical, social, and financial health....Here are the main elements of a treatment plan.Diagnostic Summary. ... Problem List. ... Goals. ... Objectives. ... Interventions. ... Tracking and Evaluating Progress. ... Planning Long-Term Care.

What is the first step in treating a drug abuse problem?

Detoxification is normally the first step in treatment. This involves clearing a substance from the body and limiting withdrawal reactions. In 80 percent of cases, a treatment clinic will use medications to reduce withdrawal symptoms, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

What are three options for drug abuse treatment?

There are many options that have been successful in treating drug addiction, including:behavioral counseling.medication.medical devices and applications used to treat withdrawal symptoms or deliver skills training.evaluation and treatment for co-occurring mental health issues such as depression and anxiety.More items...•

What are the five treatment approaches?

2001#N#Description: This multidimensional instrument assesses five treatment approaches: psychodynamic or interpersonal, cognitive–behavioral, family systems or dynamics, 12–step, and case management. For each of the first four modalities, items assess beliefs underlying the approach, practices appropriate in individual therapy, and practices appropriate in group therapy. Case management is an individual approach, so no group practices items were included. In addition, items were developed to tap general “group techniques” (e.g., “encouraging peer social support”) and “practical counseling” (e.g.,“developing rapport and trust”). The instrument consists of 48 items that assess 14 subscales. Construct validity was supported by the results of a confirmatory factor analysis in which subscale items loaded on the factor they were intended to assess, but not on other factors. Corresponding belief and practice subscales correlated highly, except for case management. Cronbach alphas for all subscales except psychodynamic and family systems beliefs were above 0.50 and most were over 0.70 (Kasarabada et al. 2001, p. 287). The fact that some of the subscales consist of only three items contributed to low internal consistency estimates.

Why do treatment providers need instruments?

How is quality of alcohol treatment determined?

The quality of alcohol treatment is determined, not only by the therapeutic techniques applied, but also by the characteristics of individual treatment providers (panel III in figure 1). In particular, this domain of variables refers to within–program variation in provider characteristics (aggregate, program–level staff characteristics are considered in panel II). Gerstein (1991) argued that “the competence, quality, and continuity of individual caregivers are likely to be critical elements in explaining the differential effectiveness of [substance abuse] treatment programs” (p. 139). In the alcohol treatment field, the few studies that have been conducted (e.g., W.R. Miller et al. 1980; Valle 1981; McLellan et al. 1988; Sanchez–Craig et al. 1991; Project MATCH Research Group 1998; for reviews, see Najavits and Weiss 1994; Najavits et al. 2000) indicate that therapist characteristics play an important role in determining clients’ treatment retention and outcomes.

What is the National Drug and Alcoholism Treatment Unit Survey?

Measure: National Drug and Alcoholism Treatment Unit Survey (NDATUS)#N#Citation: Office of Applied Studies 1991#N#Description: The NDATUS is a brief questionnaire (five pages) that covers (a) the overall organization and structure of programs (ownership, funding sources and levels, organizational setting, capacity in different treatment settings using different treatment modalities, hours of operation, etc.), (b) staffing and staff characteristics, (c) services (e.g., methadone dosages), (d) policies, and (e) clients and client characteristics. The 1989 NDATUS was augmented in 1990 by the Drug Services Research Survey (DSRS) (Office of Applied Studies 1992 a, 1992 b) to obtain additional data in the areas of facility organization and staff, client data, services, and costs and charges. Using data from the 1991 NDATUS, Rodgers and Barnett (2000) found that private, for–profit substance abuse treatment programs tended to be smaller and more likely to provide treatment in only one setting. Public programs and nonprofit programs generally had more treatment staff; Federal and for–profit programs had more psychologists and physicians. In 1992, the NDATUS evolved into the Uniform Facility Data Set (UFDS), sponsored by the Office of Applied Studies.

What is alcohol treatment?

Alcohol treatment programs typically provide psychosocial and/or pharmacologic interventions to patients. To the extent that it is constant across all patients, treatment provided is a program–level characteristic (panel II in figure 1). In most programs, however, the treatment provided varies across patients (panel V).

What are the factors that affect the impact of alcohol treatment?

Therapeutic Alliance. One of the key factors affecting the impact of alcohol treatment, especially psychosocial treatments, is the quality of the alliance or relationship that is developed between the therapist and client (panel IV in figure 1).

What are program level characteristics?

Program–level characteristics (panel II in figure 1) are general factors related to the program’s organization and structure, policies, services, treatment orientation, social environment, and readiness for organizational change.

What is the primary goal of assessment?

Within the clinical context, the primary goal of assessment is to determine those characteristics of the client and his or her life situation that may influence treatment decisions and contribute to the success of treatment (Allen 1991). Additionally, assessment procedures are crucial to the treatment planning process.

What is client-treatment matching?

Client–treatment matching attempts to place the client in those treatments most appropriate to his or her needs. There are a number of dimensions on which treatments may vary and which need to be considered in attempting to make an appropriate referral or match (Marlatt 1988; W.R. Miller 1989 b; Institute of Medicine 1990; Donovan et al. 1994; Gastfriend and McLellan 1997). Among these dimensions are treatment setting (e.g., inpatient, residential, outpatient), treatment intensity, specific treatment modalities, and the degree of therapeutic structure. A number of possible variables may interact with these dimensions to lead to differential outcomes, making the clinician’s task more difficult.

What is Shiffman's theory of relapse proneness?

Shiffman (1989) suggested that three levels of information are necessary in order to gain a sense of the individual’s “relapse proneness,” and thus are relevant to treatment planning. These fall along a continuum of their proximity, in both time and influence, to the probability of relapse.

What are the stages of alcohol abuse?

The first two stages involve screening, case finding, and identification of a substance use disorder; an evaluation of the parameters of drinking behavior, signs, symptoms, and severity of alcohol dependence, and negative consequences of use; and formal diagnosis of alcohol abuse or dependence.

What is self efficacy in alcohol?

To measure self–efficacy concerning alcohol abstinence, defined in terms of temptation to drink and confidence about not drinking in high–risk situations. Identifies high–risk situations in which. the individual is highly tempted and has low levels of confidence; aids in developing relapse prevention interventions.

What are the steps of assessment?

Here are eight steps you should include in your assessment process: Determine objectives, scope and goal: You want to be clear about why you are undertaking the assessment and your goal for how you will use the results. Defining this will help you determine ...

What is awareness session?

Awareness sessions that describe industry benchmarks and best practices are a good way of creating awareness of the assessment purpose and increase the desire for change. This also lessens the fears and promotes open dialog about the current state.

When to include assessment in a document?

You’ll find yourself writing a lot of assessments throughout your career. Most commonly, you’ll include an assessment when completing daily notes, documenting progress notes, or writing an evaluation. But no matter the occasion, the assessment component can become the most time-consuming portion of your documentation.

What is physical therapy assessment?

A great therapy assessment accomplishes two things: It highlights the necessity for skilled therapy. It identifies areas to address in future treatments.

How to evaluate a PT?

Try following this simple outline for an evaluation assessment: 1 Restate the diagnosis 2 Remark on the patient’s rehab potential 3 Identify their key impairments 4 State why skilled PT is necessary

How long does it take to write a note for a therapist?

Without these resources, writing each note can take up to 10 minutes per patient, per day.

Do you need to write a paragraph for a skilled assessment?

You don’t need to write a paragraph for this type of documentation, but being too brief could diminish important aspects of your skilled assessment. Focus on the key elements you worked on in the session. If you targeted balance training, your assessment should reflect why.

Is assessment the most time consuming part of documentation?

But no matter the occasion, the assessment component can become the most time-consuming portion of your documentation. Learning how to write efficient, effective notes early on will save you precious time. To start, let’s look at some example therapy assessments.

What is the purpose of screening, assessment, and treatment planning?

Screening, assessment, and treatment planning (see Table 1, Key Definitions) constitute three interrelated components of a process that, when properly executed, informs and guides the provision of appropriate, client-centered services to persons with co-occurring disorders (COD). Clients with COD are best served through an integrated screening, assess-ment, and treatment planning process that addresses both substance use and mental disorders, each in the context of the other. This paper discusses the purpose, appropriate staffing, protocols, methods, advantages and disadvantages, and processes for integrated screening, assessment, and treatment planning for persons with COD as well as systems issues and financing.

Who can do integrated assessment?

Integrated assessment may be conducted by any mental health or substance abuse professional who has the spe-cialized training and skills required. DSM-IV-TR diagnosis is accomplished by referral to a psychiatrist, clinical psychologist, licensed clinical social worker, or other qualified healthcare professional who is licensed by the State to diagnose mental disorders. Note that certain assessment instruments can only be obtained and administered by a licensed psychologist. In some cases (e.g., persons without a confirmed diagnosis of either a substance use or mental health disorder, and persons with additional special needs such as homeless or dependent adults), an assessment team including substance abuse and mental health professionals and other service providers may be needed to complete the assessment. Generally, assessment occurs in a mental health or substance abuse treatment

What is client centered treatment plan?

The client-centered treatment plan is the joint responsibility of the clinician or clinical team and the client. The client-centered plan is guided by what the client wishes to accom-plish and the methods that are acceptable to him or her. In systems where care is managed, some aspects of the plan may require authorization by payors. Securing service au-thorization is the responsibility of the providers. If a provider is unable to obtain service authorization, the client and the provider should explore together what possible modifications to the treatment plan will best meet the client’s needs and satisfy reimbursement requirements.

What is integrated treatment planning?

Integrated treatment planning addresses both mental health and substance abuse, each in the context of the other dis-order. During integrated treatment planning phases, initial decisions are made about what services the client needs and wants, where these services will be provided, who will share responsibility with the client for monitoring progress, how the services of different providers will be coordinated, and how services will be reimbursed. The latter will sometimes involve seeking service authorization to obtain reimburse-ment, which may, in turn, place constraints on the treatment #N#plan or require revisions of it. Treatment planning should be client centered, addressing clients’ goals and using treatment strategies that are acceptable to them.

What are the methods of information gathering?

Information-gathering methods for screening may include screening instru-ments, laboratory tests, clini-cal interviews, and personal contact. The circumstances of contact, the client’s de-meanor and behavior, signs of acute intoxication, physical signs suggesting drug use or attempts at self-harm, and information offered spon-taneously by the client or intimates can be

What are assessment instruments?

Assessment instruments constitute a structured method for gathering information in many areas, and for establishing assessment scores that define problem areas. Appendix G, pages 487–495 of TIP 42 (CSAT, 2005) provides rel-evant examples of instruments that may be used in the assessment of COD. Assessment instruments also can function as “ticklers” or memory aids to the clinician or team, assisting in making sure that all relevant topics are covered.

What is integrated screening?

Integrated screening addresses both mental health and substance abuse, each in the context of the other disorder. Integrated screening seeks to answer a yes/no question: “Is there sufficient evidence of a substance use and/or other mental disorder to warrant further exploration?” A compre-hensive screening process also includes exploration of a variety of related service needs including medical, housing, victimiza-tion, trauma, and so on. In other words, screening expedites entry into appropriate services. At this point in the screening, assessment, and treatment planning process, the goal is to identify everyone who might have COD and related service needs.

What is the purpose of a nurse's assessment?

In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment.

What is the problem part of a nursing diagnosis?

Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.

What are the options in nursing care?

Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process. The client reports nausea and constipation.

What is the responsibility of the nurse conducting the interview and initiating the relationship?

The management of the client's anxiety is the responsibility of the nurse conducting the interview and initiating the relationship. The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress.".

What is the diagnostic phase of nursing?

Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process.

How to discontinue a diagnosis?

Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records.

What is actual health problem?

An actual health problem is a client problem that is currently present. The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature.

Patient Characteristics

Program–Level Characteristics

Provider Characteristics

Therapeutic Alliance

Treatment Provided/Treatment Involvement

Proximal Outcomes

Ultimate Outcomes

Table 1.—Measures of General Program–Level Characteristics

Table 2.—Measures of Treatment Orientation

Treatment Provided/Patient Involvement in Treatment

In pharmacologic studies, treatment provided and patients’ compliance with treatment are assessed in terms of medications taken. Developments such as Medication Event Monitoring System (MEMS) vials that record the dates and times they are opened (e.g., Namkoong et al. 1999; Krystal et al. 2001) can yield more accurate compliance data than patient r...

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Problem Recognition, Motivation, and Readiness to Change

Alcohol–Related Expectancies and Self–Efficacy

Perceived Locus of Control of Drinking Behavior

Measures of Family History of Alcohol Problems

Extra–Treatment Social Support

An important area to consider as part of the assessment process is the extent and nature of the individual’s social support system. Perceived social support may serve as a moderator of the relationship between a positive family history of alcoholism and the development of alcohol problems (Ohannessian and Hesselbrock 1993). Litman (1986) noted that...