CLINICAL RECORD SYSTEM FOR DRUG ABUSE TREATMENT PROGRAMS

• NCJ Number: 54861
• Author(s): ANON
• Date Published: 1978
• Length: 163 pages
• Contract Number(s): 271-75-1139
• Sponsoring Agency: US Dept of Health, Education, and Welfare
• Corporate Author: Macro Systems, Inc
• Sale Source: Superintendent of Documents, GPO; National Institute of Justice/
• Language: English
• Country: United States of America
• Note: TREATMENT PROGRAM MONOGRAPH SERIES N 5

Annotation

THIS MONOGRAPH DELINEATES THE USES OF GOOD CLIENT RECORDKEEPING SYSTEMS, PROVIDES A CORE SET OF RECORD FORMS FOR USE BY DRUG TREATMENT PROGRAMS, AND INSTRUCTS PERSONNEL IN THE USE AND APPLICATION OF THE SYSTEM.

Abstract

THE CLIENT RECORD SYSTEM PRESENTED IS INTENDED AS A TOOL TO FOSTER AND MAXIMIZE POSITIVE CHANGE IN CLIENT BEHAVIOR, ATTITUDES, AND LIFESTYLE. THE SYSTEM PRESENTED IS COMMONLY KNOWN AS 'PROBLEM-ORIENTED RECORDKEEPING.' IT INCLUDES THE FOLLOWING BASIC ELEMENTS: COLLECTION OF BASIC MINIMUM DATA ON EACH PATIENT; A STATEMENT OF THE PATIENT'S MAJOR PROBLEMS, RANKED IN ORDER OF IMPORTANCE AND NUMBERED; A TREATMENT PLAN, THE ACTION COMPONENTS OF WHICH ARE NUMBERED TO CORRESPOND TO THE PROBLEMS IDENTIFIED; AND PROGRESS NOTES LIKEWISE NUMBERED AND USED TO TRACK THE CLIENT RESPONSE TO TREATMENT. THE OVERALL VALUE OF THE SYSTEM IS ITS CAPABILITY TO FUSE DIVERSE TREATMENT ELEMENTS INTO AN EFFECTIVE CLIENT-ORIENTED FOCUS. THE CORE SET OF FORMS USED IN THE SYSTEM ARE AS FOLLOWS: (1) INITIAL INTERVIEW FORM, WHICH IS AN INTAKE INSTRUMENT THAT GATHERS SALIENT BACKGROUND INFORMATION ABOUT THE CLIENT; (2) HEALTH QUESTIONNAIRE AND PHYSICAL EXAMINATION FORMS; (3) INDEPTH INTERVIEW FORMS, WHICH EXPLORE THE CLIENT'S BACKGROUND IN DRUG USE, LEGAL, PSYCHOSOCIAL, EDUCATIONAL, AND EMPLOYMENT HISTORIES; (4) TREATMENT PLAN FORM, ON WHICH PROBLEMS, GOALS, AND ACTION PLANS ARE NOTED; (5) TREATMENT PLAN REVIEW FORM, ON WHICH THE TREATMENT PLAN IS PERIODICALLY EVALUATED; (6) PROGRESS NOTES, WHICH RECORD CLIENT PROGRESS IN RELATION TO PROBLEMS DEFINED IN THE TREATMENT PLAN; AND (7) DISCHARGE SUMMARY, WHICH RECAPITULATES THE TREATMENT RENDERED, INDICATES THE CLIENT'S RESPONSE, AND RECORDS THE CLIENT'S STATUS UPON LEAVING THE PROGRAM. SAMPLES OF THESE FORMS ARE PROVIDED AND THEIR USE AND PURPOSE DESCRIBED IN DETAIL. SPECIFIC USES OF THE RECORD SYSTEM IN CLINICAL CASE MANAGEMENT ARE DISCUSSED, AND THE CLIENT RECORD SYSTEM IS RELATED TO VARIOUS FUNCTIONS OF PROGRAM MANAGEMENT. SAMPLES ARE ALSO PROVIDED OF FORMS USED IN THE SYSTEM IN ADDITION TO THE CORE FORMS. (RCB)