Detox Note

Data:
Patient and therapist met to create detox treatment plan, complete Phq 9, Gad 7, BAM assessment and Columbia since last contacted. 
Patient and Therapist discussed Length of Stay and patient agreed to: [select name="variable_1" value="Detox only | FLOS | Presents as AA Risk| Willing to try Residential"]
 
 
Assessment: 
Patient was [checkbox name="variable_1" value="Engaged | Unengaged | Participated| Refused to participate| Shared appropriately| Demonstrated insight| Demonstrated lack of insight| Positive | Negative| Open | Closed| Receptive | Un receptive"] [textarea name="variable_1" default="   "]

BAM Use Score: [text name="variable_1" default="sample text"]
BAM Risk Score: [text name="variable_2" default="sample text"]
BAM Protective Score: [text name="variable_3" default="sample text"]
GAD-7:  [text name="variable_4" default="sample text"]
PHQ-9: [text name="variable_5" default="sample text"]
Columbia Since Last Contact: [checkbox name="variable_2" value="0| 1| 2| 3| 4"]

Conscious/Orientation: A+OX4
ADl's: [checkbox name="variable_5" value="Appropriate | Not appropriate| Concerns |No concerns"]
Psychomotor / Behavioral concerns: [checkbox name="variable_6" value="No Concerns | Concerns "] [textarea name="variable_10" default=" "]
Cooperation: [checkbox name="variable_8" value="Cooperative | Uncooperative"] 
Speech: [checkbox name="variable_9" value="Appropriate rate and volume | inppropriate rate / volume"]
Affect: mood congruent, tearful at times discussing sensitive topics
Thought process: linear, logical, and goal-oriented
Thought content: no concerns at this time
Perceptions : [checkbox name="variable_11" value="No evidence of Delusions or Hallucinations | Evidence of Delusions or Hallucinations"] [textarea name="variable_152" default="  "]
Concentration: Appropriate/no concerns
Memory: no impairment
Judgement: poor
Insight: poor

W/Ds observed:
-Insomnia or other sleep disturbances
-Anxiety
-Depression
-Impaired concentration
-Fatigue or low energy
-Foggy thought process
-Poor impulse control
-Increased sensitivity to stress
-Alcohol or other drug cravings

Needs continued level of care as evidenced by:
-Lack of discharge plan
-Severe withdrawal sx
-Lack of setting up safety plan to returning home
-Severe risk of relapse

24 hour care:
-Continued severe withdrawals
-Inability to manage emotional dysregulation without using
-Patient has severe cravings
-Patient needs constant monitoring for increased ability for use skills to remain sober

Relapse risk: high

Plan: Therapist will continue to coordinate detox and provide appropriate intervention.  Patient will continue to engage in medically monitored detox overseen by staff.