AA DAP Note

This writer met with [text name="variable_9999" default="sample text"] and engaged [text name="variable_9999" default="sample text"] with MI to assess AA risk and determined interventions for AA block were needed and utilized discharge planning as a goal for [text name="variable_9999" default="sample text"] to focus on.

This writer provided [text name="variable_9999" default="sample text"] with homework to focus on working with caseworker and family with this writer to plan for safe continued care plan before looking into discharge

This writer involved: [text name="variable_9999" default="sample text"] [checkbox name="variable_1" value="Emergency Contact| Spouse| Parent| Sibling| Other Family members| Friends| Primary Therapist| Case manager| Nursing| leadership| Other "]

Collaterals reported [checkbox name="variable_2" value="LOS Expectations| Expectations of treatment| Not willing to pick them up| Willing to pick them up| Set boundaries| Struggled to hold boundaries| concerns with repeated sud bx| Concerns with emotional health and bx"]

Psychoeducation **** [text name="variable_9999" default="sample text"] has been informed of the risks of leaving including (But not limited to) all the Paws, reasons for continued level of care, and reasons for 24 hour care needed. [text name="variable_9999" default="sample text"] acknowledge that leaving AA and been informed that leaving can be lethal to [text name="variable_9999" default="sample text"] d/t these sx. This writer also informed pt that physical, psychological, emotional, social, and spiritual damages can occur d/t AAing and not completing program. Furthermore, [text name="variable_9999" default="sample text"] was informed of these damages leading up to death may occur with relapse and not following clinical advice. [text name="variable_9999" default="sample text"] still stated they want to leave and understands the risks. Medical staff, case management, clinical team, RSS, and all unit staff have expressed their concerns to this pt. [text name="variable_9999" default="sample text"] acknowledged understanding these risks and concerns. [[text name="variable_9999" default="sample text"] also expressed how their substance use has impacted their lives negatively and still reports they want to leave AA understanding all the risks involved. ***

[text name="variable_9999" default="sample text"] Identified Barriers including: [checkbox name="variable_5" value="Work| Relationships| Anxiety| Depression| Frustrations| Wanting personal technology| Unwilling to adhere to tx expectations| Not liking tx| Program refusal| Isolative bx| Refusal to engage in therapeutic activities| Reports they refuse or do not want to be in tx| Other "] [textarea name="variable_8" default=" "]

Exploration of solutions to barriers"[textarea name="variable_100" default=" "]


Assessment:This writer met with [text name="variable_9999" default="sample text"] to engage in AA blocking to discuss ways to say and increase self regulation to reduce the impulsivity to AA

Orientation [checkbox name="variable_19999" value="A&Ox4| Disoriented| Out Bounded"]

Behavior: [checkbox name="variable_155555555" value="aggressive | Engaged| Disengaged| Willful| Closed off| Evasive| Over friendly| Calm| Agitated| In acute distress| frustrated| Insecure| fearful| Willful| willing"]

Cooperation:[checkbox name="variable_001" value="Fair|Poor"]

Clinical Concerns: [checkbox name="variable_11111111" value="anxiety| Depression| Impulse Control| Lack of boundaries| Lack of sober support| Willfulness| Outside Stressors| Evasiveness| lack of engagement in treatment| Ongoing psychosocial stressors| other "] [textarea name="variable_789456123" default=" "]



Plan:
[checkbox name="variable_122" value=" they are to report to this writer and other clinical staff clinical and case management concerns. they will continue to bring up their concerns. they recommended to follow with current level of care, therapy, and continue to comply with all medical recommendations. they will continue to engage in daily therapeutic activities, meals, and weekly / prn therapy sessions, family sessions, and other meetings based on pt need. they will continue with rx daily medication managed by medical and nursing team. they will bring up all medical concerns to nursing and medical staff. Multidisciplinary team will continue to address concerns brought up by they and discuss ways to address concerns and questions. they family will continue to be contacted through they stay (based on pt status with ROI and consents).they to continue discussing positives and negatives of AA and communicating with staff about what they need and staff to in crease psychoeducation and ongoing AA blocking Multidisciplinary team to follow up with concerns brought up that are relevant to their field. Team to continue to monitor and address concerns brought up in this discussion | they recommended to: they to continue with current level of care and therapy, to continue with weekly family and individual therapy, daily therapeutic processing groups, programming, and other groups. Continue with rx daily medication management via medication management team PRN. they to do appropriate programming. they going against medical recommendation to leave and has acknowledged the risks. Current plan of recommendation is for pt to stay. they reports they will do their plan going forward against advice Multidisciplinary team to follow up with concerns brought up that are relevant to their field. Team to continue to monitor and address concerns brought up in this discussion "]