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Substance Abuse: Case Study

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DAP Progress Note DSM-5 DIAGNOSIS(ES): Opioid Use Disorder: Severe DAP FORMAT D - Data Patient observations, thoughts, direct quotes. Substance use and review of dose, dosing compliance and drug screens. Review of last session, group attendance and outside provider compliance. Any illicit substance abuse? Y If yes, name(s) of substance, route of transmission, amount: The paitent smokes THC every couple of days Does the patient feel comfortable on their current dose? Y Paperwork completion during session: State (MTQAS, WITS) Tx Plan N Aftercare Plan N Other N Data: The patient arrived on time for his counseling session. Reported stability on his current dose and denies the need for a dose increase when offered. Please note, the patient accepted a dose decrease about a week ago and reported that he is adjusting fine with the change. During the course of the session, the patient discuss about the philosphy of Alan Watts-Zen and Buddhism. The patient reflects about his life and his current practice of such religion as it reflects of who he is as a person and about…show more content…
Assessment: The patient appeared to be alert, very engaging during the counseling session, and No evidence of SI/HI. The patient does his treatment plan goals in every counseling session and his coping mechanism. P - Plan The treatment plan moving forward based on the clinical information acquired and the assessment. Homework assignments, any change of frequency of service or level of care and expectations before next appt. Next scheduled appointment: 4/20/2017 at 10am. Plan: The patient enjoys seeing this writer weekly as it is helpful for him to have someone to talk with as therapeutic. In essence, the patient will continue to meet with this writer weekly to address his recovery
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