In the General Info TAB-Social Security Number – Enter the client Social Security Number as 123-45-6789 (dashes needed to ensure consistency when searching the data base); if none enter 000-00-0000 and explain in your narrative.
- Demographic Information.
- Presenting Problem/Primary Complaint.
- Medical History.
- Education, Employment and Military History
- Drug and Alcohol History.
- Legal History
- Family History.
- Behavioral Health History
- ASAM Criteria
- Diagnosis/Summary/Recommendations
In the Demographic Information TAB.
What was your current age on the moment of the last information update? | DI.2 This field is auto-calculated by taking the current date minus the date of birth to calculate the current age at the time of the last information update. |
In the Presenting Problem/Primary Complaint TAB.
When were you first referred to have this assessment? | PP.1 The intent of this question is to capture the length of time between the date the client was first referred and the current date. |
What is the PRIMARY reason for your having this assessment? | PP.2 Enter the client’s words for his or her primary problem or primary complaint |
What led you/motivated you to schedule this evaluation? | PP.3 Enter the client’s own words for what led him or her to schedule the appointment. |
All other items in this section are self-explanatory.
In the Medical History TAB.
All items in this section are self-explanatory.
In the Education, Employment and Military History TAB.
All items in this section are self-explanatory.
In the Drug and Alcohol History TAB.
For every substance a client has ever used, the client makes a rank order of those substances. For each substance used there is a Comments Field. The counselor uses this field to write a history of the client’s use that captures the individual patterns for frequency and amounts used. This is where there is documentation of tolerance, withdrawal and periods of abstinence. Individual patterns of use justify the diagnosis of a substance use disorder. Usually a client has a primary drug of choice (ranked #1 and likely the primary diagnosis). There may be additional substances used that will justify additional diagnoses. Often there are substances used one time or rarely and have never met criteria for a substance use disorder. The counselor notes this in the Comments field.
All other items in this section are self-explanatory.
In the Legal History TAB.
Note – To save time, all items from LE.3 to LE.23 are defaulted to “No” and must be changed to “Yes” if appropriate.
All other items in this section are self-explanatory.
In the Family History TAB.
Note – To save time, all items from FH.18.1 to FH.18.12 are defaulted to “Yes” and must be changed to “No” or “n/a” if appropriate. “n/a” should be used if there has been no contact with the person identified in the past 30 days or if never in a lifetime.
Note – To save time, all items from FH.19.1 to FH.19.18 are defaulted to “No” and must be changed to “Yes” or “n/a” if appropriate. “n/a” should be used if there has been no contact with the person identified in the past 30 days or if never in a lifetime.
In the Behavioral Health History TAB.
Note – To save time, all items from BH.4 to BH.21 are defaulted to “No” and must be changed to “Yes”, if appropriate.
In the ASAM Criteria TAB.
ASAM Criteria ratings are often required when completing substance abuse evaluations. As a time saver for the counselor a Table is offered that allows the rating of 0 to 4 for each of the six dimensions of the ASAM Criteria. There is a Field for Counselor for the counselor to type a narrative rational for the rating provided
In the Diagnosis/Summary/Recommendations TAB.
This TAB is offered again to save the counselor time in formatting and typing for each evaluation report.
In the Diagnosis section the counselor provides the DSM-5 code for the Primary Diagnosis; then, in the Additional Diagnoses section the counselor provides additional diagnoses or rule outs for each client.
In the Summary and Rationale section the first paragraph is auto-populated from the Reason for Referral. The counselor now provides the summary of the pertinent findings from the assessment and provides a rationale for the diagnosis. Often the counselor will cite the criteria met from the DSM-5 for each diagnosis made.
In the Recommendations section the counselor is offered a checklist of recommendation options, All levels of care from the ASAM Criteria are listed along with some other frequently used recommendations that may be pertinent to a client’s care.
NOTE in the Agency/Counselor Setup there is the ability to add your favorite recommendations to the list already offered. Go to Setup and click on Manage Recommendations. Click on Add New Recommendations then type in the new recommendation and click add new recommendation. There you can also delete recommendations you may never use.