Documentation, Patient Records and Substance Abuse Treatment

Course overview

Course Description: This course reviews the essential elements in a client record in substance abuse treatment settings. It reviews the steps in the treatment process, from first contact to transitioning to a different level of care, specifying the components of the client record that are required at each stage of treatment. Tips for documentation that meets legal and ethical requirements are included throughout. Strategies for collecting the required information are also reviewed. Elements that are required in the assessment and treatment planning stages are discussed in detail. Best practices for documentation are discussed in depth. Confidentiality and privacy concerns are included as are known limits to confidentiality. Chapter 42 CFR, Part 2 is covered in as part of federal law relating to substance abuse records. How to develop and document an individualized treatment plan is covered in detail. Methods for planning a clients transition and discharge are covered. Record reviews and quality assessment for client records are discussed. This course is appropriate for drug and alcohol counselors, peer counselors, recovery residence administrators and other professionals who work in substance abuse treatment facilities. This course is designed for entry level practitioners. This course is based upon material complied from multiple sources, which have been edited to produce a simple but comprehensive review of the common elements required in client records in substance abuse treatment. Authors: TM DiDona Learning Objectives: This course will provide the practitioner with detailed information regarding documentation and patient records in substance abuse treatment. Specifically, a professional will: Describe required components in a client record in substance abuse treatment settings. Identify confidentiality requirements for substance abuse records, including those from Chapter 42 CRF, Part 2. Recognize what will be reviewed in a client record review and how to ensure quality records. Citation: DiDona, TM (2017). Documentation, Patient Records and Substance Abuse Treatment.