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Substance abuse discharge summary example

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The document is a discharge summary for clients undergoing substance abuse treatment at HealthChoice and PAC. It includes sections for client information, treatment details, discharge reasons, aftercare plans, and confidentiality notices. The summary emphasizes the importance of protecting patient information under federal regulations and outlines the necessary steps for documenting the client's treatment progress and future care.

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Why have a discharge summary?

A discharge summary is a collection of information about events during care of a patient by a provider or organisation. The document is produced during a patient's stay in hospital as either an admitted or non-admitted patient, and issued when or after the patient leaves the care of the hospital.

What should be included in discharged planning?

Your discharge plan should include information about where you will be discharged to, the types of care you need, and who will provide that care. It should be written in simple language and include a complete list of your medications with dosages and usage information.

How do you write a medical discharge summary?

These are summarized as follows: Reason for hospitalization: description of the patient's primary presenting condition; and/or. ... Significant findings: Primary diagnoses. Procedures and treatment provided: ... Patient's discharge condition: ... Patient and family instructions (as appropriate): ... Attending physician's signature:

What are the 5 phases of recovery?

What Are the Five Stages of Change? The five stages of addiction recovery are precontemplation, contemplation, preparation, action and maintenance.

What does Asam level .5 mean?

Level 0.5: Early Intervention. Early intervention are services for specific individuals who, for a known reason, are at risk of developing substance- related problems, or a service for those for whom there is not sufficient information to document a substance use disorder.

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What is in the discharge summary section?

A discharge summary is a handover document that explains to any other healthcare professional why the patient was admitted, what has happened to them in hospital, and all the information that they need to pick up the care of that patient quickly and effectively.

What should be documented in discharge summary?

Information for the patient. Most discharge letters include a section that summarises the key information of the patient's hospital stay in patient-friendly language, including investigation results, diagnoses, management and follow up. This is often given to the patient at discharge or posted out to the patient's home ...

How many levels of care are identified in ASAM criteria?

Although five broad levels of service are described in The ASAM Criteria, these levels represent benchmarks along a single continuum of care. These levels are linked to one another, and patients can move among and between them based on their current needs.

What does Asam Level 1 mean?

Level 1 services may be offered in any appropriate setting that meets state licensure or certification criteria (The ASAM Criteria, p 187). This level of service and the array of settings in which it is offered provides maximum flexibility to meet the treatment needs of patients at different stages of an SUD.

What information is found on the patient's discharge summary?

Discharge summary This report is completed after the patient is discharged from the hospital. The report is a summary of the admission to the hospital, care provided, the diagnosis, procedures, medications, tests, immunizations, any problems and the plan for care after discharge from the hospital.

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