Opioid Abuse Treatment-Outpatient Client Record Review
I would like a sample of comprehensive initial psychiatric charting/assessment for a client looking for substance abuse treatment ( opioids, alcohol e.t.c)
Below is only a sample of some of the things required. I need a mock chart
OUTPATIENT CLIENT RECORD REVIEW
Admission and Intake Data
Date and Type of Admission
ID/Demographic Info
Social/Econ/Family History
Education
Employment History
Criminal History/Legal Status
Physical and Mental Health History
AOD History
Previous Treatment
Emergency Contact
Current Living Arrangements
Referral Source/Reason
Authorization to Release Information
Signed Client Rights
Health/Medical
Health Screen/Questionnaire
Medical Referrals (If Applicable)
Records of Medication (if Applicable)
Drug Screening Results
Plans: Should include referral to Intensive outpatient therapy treatment program for substance abuse
Labs e.t.c
‘
Outpatient Client Record Review
Name
Course
Institution
Date
Opioid abuse treatment-Outpatient Client Record Review
Admission and Intake Data
Information
Date and Type of Admission
The date and time of admission are recorded and client has a history of anxiety
The type of admission is for opioid drug addiction (substance use disorder)
ID/Demographic Info
First, middle and last name are included
The client was born 1st May 1970 and is a 15 year old male
He is a mechanic and is married with three children
He is a history of alcohol use, but has been diagnosed with substance abuse because of opioid addiction
He is currently addicted to opioids after having been diagnosed with opioid medication following a vehicle accident
However, he no longer feels pain from the accident
Social/Econ/Family History
Record the Socioeconomic Status as reported from low, middle and high SES
Record family background and history
Record the family conditions
Education
Associate degree with certifications and training over years
Employment History
Experience in various industries, but currently self employed
Criminal History/Legal Status
There is no criminal history and has mostly been fined for traffic infractions
Physical and Mental Health History
Onset of mental health history problems
Aggravating factors – alcohol use, family problems
Treatments previously tried
Mental status examination (MSE) shows he is affected by anxiety and substance abuse disorder
Include history of alcohol and drug use
AOD History
Record of Alcohol and other drug (AOD) abuse
Given ongoing sym...
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