Discharge Summary Detox only
Patient was admitted on [text name="variable_1" default="sample text"] to Recovery Centers of America for: Patient successfully completed Level 3.7 medically managed detox. Patient was assessed, monitored, and medicated by the medical physician and nursing staff. At the time of discharge, patient denied any physical withdrawal symptoms. Patient 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. to Patient met with a primary therapist for individual sessions and group therapy sessions. Goals Patient made progress towards goals by engaging in: therapeutic programming and implementing skills, understanding boundaries, and recognizing the need for sobriety Patient continues to need to address concerns related to: [textarea name="variable_1" default="sample text"] Patient completed a continuing care plan, which included follow up with / referrals for [checkbox name="variable_1" value="Medication Management | Substance abuse treatment | Therapist | PHP | IOP | Sober Living| Other "] [textarea name="variable_3" default=" "] Patient is [select name="variable_1" value="In agreement | Not in agreement"] with RCA CCP Reccomendation indicating movement[select name="variable_2" value="Towards | Awa"] their insight, goals and judgement Substance Use [checkbox name="variable_10" value="Substance use: At the time of discharge, patient denied using any substances while at treatment and reports that pt continues to want to work towards sobriety and is willing to continue with treatment step down process and open to next steps.|Substance use: At the time of discharge, patient did not use substances while at RCA, but continues to be resistant to steps going forward with tx. Patient continues to report significant cravings and struggles to think of ways to engage in tx. | Substance abuse: At the time of discharge, patient denied cravings for substances and reported that they will continue to work at a LLOC other than residential against clinical recommendation of residential. patient continues to report motivation to continue with tx, desire to stay sober, and agreement that if patient starts to have behaviors, they will return for HLOC assessment. patient reports feeling that they are able to manage their cravings and stay sober in LLOC other than residential"] AA Discharge Patient was admitted on [text name="variable_1" default="sample text"] to Recovery Centers of America for: Patient did not sucessfully complete Level 3.7 medically managed detox. Patient was assessed, monitored, and medicated by the medical physician and nursing staff. Patient refused to comply with treatment and medical reccomendations while at RCA which included medical monitoring, addressing medical needs, psychaitric needs, and other needs on an as needed basis appropriate or medication, psychaitric, nursing, and all other clinical follow ups including primary therapist, CM and group therapy sessions. Goals patient made minimal / no progress towards goals aeb: Being resistant to all treatments, continually pushing towards wanting to use again, and struggling to see their need to be in treatment. patient ultimately decided to AA and not engage in continued treatment patient continues to need to address concerns related to: increased appropriate judgement and insight to understand seriousness of illness, need for appropriate stepdown, and how their engagement in substance use is impacting their relationships with others. Patient completed a continuing care plan, which included follow up with / referrals for [checkbox name="variable_1" value="Medication Management | Substance abuse treatment | Therapist | PHP | IOP | Sober Living| Other "] [textarea name="variable_3" default=" "] to address needs after residential level of care. Pt resistant to following recommendations of completing current program and stepdown to residential. Patient’s family struggled with discussing these concerns, but ultimately allowed patient to d/c Patient not agreement with RCA CCP recommendation indicating movement away from insight and healthy judgement d/t not able to see true need for tx and seriousness of illness Substance Use [checkbox name="variable_111" value="Substance use: per patient report, they have an over competent view stating that they do not having cravings and will not use with high confidence which is incongruent with patient presentation aeb: Significant resistance towards programming and creating goals and continued AA. This creates high potential for relapse d/t significant resistance. | Substance use: per pt report, they do not want to continue with tx and do not want to make any changes and continue to report cravings with low confidence that they will remain sober. Pt continues to have congruent presentation aeb: Sx of withdrawal and PAWS. Pt has significant resistance towards programing and creating goals and continuing AA, this creates a high potential for relapse d/t significant resistance "]
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Sandbox Metrics: Structured Data Index 0.55, 11 form elements, 385 boilerplate words, 2 text boxes, 3 text areas, 4 checkboxes, 2 drop downs, 26 total clicks
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