Discharge Summary

Detox Complete Discharge Summary
[text name="variable_1" default=" "] Was Admitted on:[text name="variable_50" default="sample text"]
For:
[text name="variable_1" default=" "] successfully completed Level 3.7 medically managed detox. [text name="variable_1" default=" "] was assessed, monitored, and medicated by the medical physician and nursing staff for psychiatric, mental health, and sud related disorders. Other dx were assessed by appropriate multidisciplinary team and addressed and monitored on an as needed basis to ensure [text name="variable_1" default=" "] is appropriate for Level 3.7 Medically Managed Detox Level of care. . At the time of discharge [text name="variable_1" default=" "] denied any physical withdrawal symptoms. [text name="variable_1" default=" "] was continually assessed for psychiatric needs and they were addressed on an as needed basis for appropriate medication, psychiatric referrals, nursing follow up, and all other appropriate clinical follow up. [text name="variable_1" default=" "] met with a primary therapist for individual sessions, family sessions and group therapy sessions. Family was contacted and engaged in as part of tx and collaborated with team and [text name="variable_1" default=" "] of agreed upon tx plan.



Goals and Objectives
[text name="variable_1" default=" "] Made progress towards goals aeb:
[checkbox name="variable_150" value="acknowledging place for coping skills | Practiced coping skills| Attended groups| Completed detox| participating in therapeutic activities| Completed CCP with staff| Wiling to explre aftercare"] [textarea name="variable_1999999999999" default="  "]
Staff utilized [checkbox name="variable_1" value="Psychoeducation|Family therapy|individual therapy| groups| Psychiatric care| addressed ongoing case management concerns | AA blocking| other"] [textarea name="variable_2" default=""].
[text name="variable_1" default=" "] struggled to make progress towards goals aeb:[checkbox name="variable_10000000000006" value="continued resistance to flos| Continued refusal to engage in programming| Evasiveness towards tx| Often unengaged| Incongruent presentation to report| refsual to create aftercare plans| resistance to completing therapeutic homework| Resistance to apply coping skills"] [textarea name="variable_3" default="    "].
[text name="variable_1" default=" "] continued care reccomendations are [checkbox name="variable_2" value="mental health| psychiatric intervention| continued SUD tx| Family Therapy| individual therapy| MAT services| case managment services| medical interventions"]
[text name="variable_1" default=" "] shows progress aeb:  [select name="variable_1" value="towards| away"]  insight and judgement aeb: [textarea name="variable_5" default="sample text"]
Clinical Concerns Expressed to [text name="variable_1" default=" "]: it was explained to [text name="variable_1" default=" "] appropriate loc and appropriate step down from detox to inpatient residential care and the benefits of a 30 day program to continue healthy habit development and ability to increase chances of sobriety. Psychoeducation from multidisciplinary staff were provided and [text name="variable_1" default=" "] was challenged to explore barriers to tx.[text name="variable_1" default=" "] Decision was to discharge Detox Only


Substance Use: 
Substance Use at time of dischargeAt time of discharge [text name="variable_1" default=" "] endorsed [checkbox name="variable_3" value="no cravings|sobriety while at RCA|wanting to continue with care|resistance to 30 day programming|cravings|struggling to engage in treatment|not wanting to continue with care|desire for sobriety|no desire for sobriety| evasiveness| symptoms of withdrawals and Paws| incongruent presentation"]


Current Risk factors
[text name="variable_1" default=" "] has protective factors including: [textarea name="variable_10" default="sample text"]. [text name="variable_1" default=" "] risk factors include: [textarea name="variable_11" default="sample text"]

Housing plans
[text name="variable_1" default=" "] housing plan includes [checkbox name="variable_13" value="Discharge back to previous living environment after staff provided psychoeducation and exploration of recovery based housing i.e. sober living, living with a sober family member, residential, and engaging in additional social supports | Discharge to sober living or outpatient with boarding| And willingness to engage in AA meetings and increase healthy social relationships."]













AA Discharge Summary: : Patient was admitted on to Recovery Centers of America for:[text name="variable_1" default=" "] did not completed Level 3.7 medically managed detox . [text name="variable_1" default=" "] was assessed, monitored, and medicated by the medical physician and nursing staff. . Other dx were assessed by appropriate multidisciplinary team and addressed and monitored on an as needed basis to ensure [text name="variable_1" default=" "] is appropriate for Level 3.7 Medically Managed Detox Level of care. At the time of discharge [text name="variable_1" default=" "] denied any physical withdrawal symptoms. [text name="variable_1" default=" "] was continually assessed for psychiatric concerns and was addressed by appropriate staff with appropriate referrals if needed.
[text name="variable_1" default=" "] family was contacted regarding [text name="variable_1" default=" "] tx and developed a plan with [text name="variable_1" default=" "] for discharge concerns.
[text name="variable_1" default=" "] met with a primary therapist for individual sessions, family sessions and group therapy sessions.Concerns discussed with [text name="variable_1" default=" "] include: [text name="variable_1" default=" "] has been informed of the risks of leaving including all the Paws, reasons for continued level of care, and reasons for 24 hour care needed. [text name="variable_1" default=" "] also acknowledged his own concerns regarding his own hx with medical complications from his substance use. This writer also informed [text name="variable_1" default=" "] that physical, psychological, emotional, social, and spiritual damages can occur d/t AAing and not completing program. Furthermore, [text name="variable_1" default=" "] was informed of these damages leading up to death may occur with relapse and not following clinical advice. [text name="variable_1" default=" "] still stated he wants to leave and understands the risks. ***

Other Discharge / AA 
[text name="variable_1" default=" "] Was Admitted on:[text name="variable_50" default="sample text"]
For:
[text name="variable_1" default=" "] did not complete Level 3.7 medically managed detox. [text name="variable_1" default=" "] was assessed, monitored, and medicated by the medical physician and nursing staff for psychiatric, mental health, and sud related disorders. Other dx were assessed by appropriate multidisciplinary team and addressed and monitored on an as needed basis to ensure [text name="variable_1" default=" "] is appropriate for Level 3.7 Medically Managed Detox Level of care.[text name="variable_1" default=" "] was discharged from 3.7 level medically monitored detox due to not being considered appropriate for current level of care. [text name="variable_1" default=" "]  was moved due to [checkbox name="variable_48561" value="HLOC | Medical Emergent Concerns| Not appropriate for 3.7 medically managed detox| DT's | Other"]  . At the time of discharge [text name="variable_1" default=" "] was agreeable to medical plan for discharge dt other reasons beyond AA, Completion etc.