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
Client met with his counselor because he needed to talk about a situation that he was bothering him. Client has concerns about this relationship and wrote a letter to his girlfriend apologizing for his behavior and wanting to make it work between to the two of them. Client shared that he explain to her the he understands how she could feel abandon and he wants to start a new. The client went on to talk about his family and their addiction. Client discuss the his two sister and father and mother were all addicted. both of the sister got clean and one has became a substance abuse counselor and other one work and well. Client further explain that he his mother went onto a program on the day after he was admitted to a program. The client doesn't
D/A: There were no medical appointments for Mr. Brown this week. Mr. Brown attended dialysis twice this week on 01/03/17 and 01/7/17 at the Fresenius Medical Center and received treatment on 01/5/17 at the Kent General Hospital. On 12/31/16, Mr. Brown was admitted to the Kent General Hospital and was discharged on 01/07/17 at 7 pm, where he was diagnosed and treated for Pneumonia and Congestive Heart Failure. Consumer has a new addition medication “Prednisone,’’ that he will be taking once in the morning for three consecutive days. Consumer did not meet with his Psychiatrist Dr. Capiro this week because he was admitted at Kent General Hospital.
During the time of assessment the patient presents drowsy. The patient reports during the time of assessment that he is not currently suicidal or homicidal. The patient reports that he hears voices telling him to kill him self and kill his wife. However, the patient reports that he loves his wife and do not wish to harm her. The patient reports that tonight that him and his wife got into an argument, however
The patient is a 42 year old female who presented to the ED with bizarre behaviors. Per documentation the patient has been not eating, nor drinking, and lying in bed the bed most of the day for the past few week. The patient presents with confusion.
Substance Use History: The patient denies any drug or substance use except for Alcohol and Marijuana; started using in high school and everyday use.
The patient appears to be happy and focused on her recovery process. This writer discussed with the patient briefly about her treatment plan goals and also, briefly discussed tapering off methadone, at which the patient is willing to pursue but at a seldom pace. There was no evidence of
Counselor met with Pt. for his monthly individual session. Counselor and Pt. discussed his progress in treatment, any medication issue, any triggers and acceptance of his TX plan. Pt. signed his Record Service sheet. Pt. indicated that he does not attend the clinic Tuesday, Saturday and Sunday and he likes having more time in his schedule because he likes to take care of his business and different errands. Pt. verbalized how hard it is to stay away from his business because worried about his employees and clients. Pt. stated, “The business is like my kid,” Pt. spoke about how he is thinking about opening a second shop around this area. Pt. commented that he isn’t experiencing serious side effects and prescribed medication is working well. Pt. informed this
This is 34 year old AAF. Patient is here to be establish as a new patient, and several compliants as listed above. Patient is a non-smoker, denies use of alcohol or illicit drug use. Patiet is acurrent resident at Lovelady Center. Patient deneis depressive moods, thoughts of suicide or homicide.current pain
Consumer stated that her meeting with “KM” benefit specialist was “very good”. Consumer stated that her week was “ok”. Consumer reported that she is happy that her brother will be discharge from the hospital as of tomorrow. Consumer stated that she hopes that her brother will deal with his issues differently after his experience with the inpatient hospitalization. Consumer stated that she takes her medications as prescribe and that she does not have any side effect other than feeling “little tired” during the day. CM explained to consumer that she may experience some side effect with her medications in the beginning. Consumer stated that she is aware of that and that she understands that she has to wait for another couple of weeks before considering changing any of her medications.
Jessica, I would like to say that I enjoyed reading your forum about substance abuse and substance use disorder. Individuals that are substance abuser does not have to have substance use disorder (Doweiko, 2015). Substance abuse does not always turn to the physical addiction of the substance (Doweiko, 2015). However, neither substance abuse nor substance use disorder are more important than the other. In both substance abuse and substance use disorder, the individual that uses the substance most likely feel that the incentive for repeating the use is more powerful than it is to not use (Doweiko, 2015). Many healthcare and human service professionals are not properly trained to treat substance abuse nor substance use disorder (Doweiko, 2015).
There are many ways to go about treatment of Substance Use Disorders. One can start with medication, behavioral therapies, and help groups. Treatment can come in many shapes and forms. It all depends on how severe and willing the patient is to go along with the treatment. Patient X in this case is very willing to change because he states, “I want to feel like a human again. I want to stop being numb to everything in my life. I feel like I’m watching my life in a video in front of my eyes.”
Boys face the stereotype of always having to be tough and confident (pg.286). So, Terrel, being an athlete, might start to consume alcohol to show his strength and to appear cool and adult-like to his peers, especially to other boys. He might also take on smoking and consuming alcohol since he has lived with his mother who has these unhealthy habits. Even, when she was pregnant with him, she was smoking and drinking and has not been successful in eliminating these habits. Prenatal exposure to smoking and alcohol raises the likelihood of a child to consume these substances early in life (FindYouthInfo 2013). Terrell grew up to be a quite healthy child despite having had a very high risk of developing FAS or FAE. But his mother continuance with these unheathy habits puts him at great risk of developing substance abuse.
In May of 2010 I was contacted and informed that my aunt was involuntarily committed
Substance abuse remains a large problem in the United States (US). According to the U.S. Department of Health and Human Services (USDHHS), substance abuse continues to take a large toll on individuals, families, and communities nationwide. In 2005, an estimated 22 million people were struggling with drug and alcohol abuse in the US. Substance abuse disrupts families, impacts work and school productivity, causes financial problems, and is related to domestic violence, child abuse, and crime (USDHHS, 2015).
This essay is based on a client Ibrahim (30 year old, male) who is currently living with his three siblings with their biological father and step mother. The client has a history of juvenile delinquency with outrageous behavior. Due the suspensions from the school, he has a low academic performance. Currently, he is jobless due to abusing drugs and low academic performance, which made him feel depressed. The purpose of the essay is to evaluate the clients’ problems with the help of consistency theory and understand the possible neurological underpinnings that may have occurred in his brain. Also recommend possible interventions that are most fitting for client.