This knowledge base article will show you how to create and complete and a Chemical Dependency Assessment.
1. From the patient's Chart Face, choose the Chem Dependency (6 ASAM Dimensions) button.
2. The Dimension 1 tab is for ASAM Dimension 1: Intoxication / Withdrawal window.
Buttons available on the first tab: (Only use the buttons that apply to your patient.)
The
button opens to the Chem Dependency window.
The
button opens to the Withdrawal Symptom Review window.
The
button opens to the CIWA window.
Intoxication / Withdrawal Risk Rating buttons give the description that you can pull into the report. In this example, 4 was chosen and the description of 4 was pulled into the yellow field (at the very bottom of the yellow field).
3. The Dimension 2 tab is for ASAM Dimension 2: Biomedical Conditions/Complications window.
Buttons available on the second tab: (Only use the buttons that apply to your patient.)
The
button opens to the Psychotropic Med History window.
The
button opens to the Current Non Psychotropics window.
The
button opens to the Medical Screen window.
BioMedical Conditions and Complications buttons give the description that you can pull into the report. In this example, 1 was chosen and the description of 1 was pulled into the yellow field (at the bottom of the yellow field). On the right, there is a list of points to consider while filling out this tab.
4. The Dimension 3 tab is for ASAM Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications window.
Buttons available on the third tab: (Only use the buttons that apply to your patient.)
The
button opens to the Global Assessment of Individual Needs window.
The
button opens to the Treatment History window.
The
button opens to the Mental Status Exam window (from the Therapy Progress Notes).
The
button opens to the Immed. Risk Factors window.
Emotional/Behavioral/Cognitive Conditions and Complications buttons give the description that you can pull into the report. In this example, 2 was chosen and the description of 2 was pulled into the yellow field (at the very bottom of the yellow field). On the right, there is a list of points to consider while filling out this tab.
5. The Dimension 4 tab is for Dimension 4: Treatment Acceptance/Resistance window
Buttons available on the fourth tab: (Only use the buttons that apply to your patient.)
The
button opens to the Dim 4 PTS to Consider window.
Risk that Client will refuse or be non compliant with treatment buttons give the description that you can pull into the report. In this example, 2 was chosen and the description of 2 was pulled into the yellow field (at the bottom of the yellow field).
6. The Dimension 5 tab is for Dimension 5: Relapse Potential window.
Buttons available on the fifth tab: (Only use the buttons that apply to your patient.)
The
button opens to the Dim 5, Points to Consider window.
The
button opens to the CD Treatment History window.
Risk of Relapse buttons give the description that you can pull into the report. In this example, 3 was chosen and the description of 3 was pulled into the yellow field (at the bottom of the yellow field).
7. The Dimension 6 tab is for Dimension 6: Recovery Environment window.
Buttons available on the sixth tab: (Only use the buttons that apply to your patient.)
The
button opens to the Support System/Social Setting window.
Risk that social environment will interfere with recovery buttons give the description that you can pull into the report. In this example, 3 was chosen and the description of 3 was pulled into the yellow field (at the bottom of the yellow field). On the right, there is a list of points to consider while filling out this tab.
8. On the last tab, Recommendation window, fill out the tab from top to bottom, left to right. When the tab has been completed, click the Compile this Note button.
9. You will be brought to the Finished Note.
10. Click the
button to sign and lock the note (if you have electronic signature).