Treatment Planning and Documentation of Treatment Progress
(1)The Opioid Treatment Program shall develop treatment plans, progress notes, and discharge plans consistent with the ASAM PPC 2R.
(2)Treatment Plan: The PTP shall develop an individualized treatment plan within 30 days of admission and shall be documented in the patient’s record. The treatment plan shall:
(a)Describe the primary patient-centered issues;
(b)Focus on one or more individualized treatment plan objectives that are consistent with the patient’s strengths and abilities and that address the primary obstacles to recovery;
(c)Define the treatment approach, which shall include services and activities to be used to achieve the individualized objectives;
(d)Document the participation of significant others in the planning process and the treatment where appropriate; and
(e)Document the patient’s participation in developing the content of the treatment plan and any subsequent modifications, with the patient’s signature,
(3)Documentation of Progress: The treatment staff shall document in the permanent record any current obstacles to recovery and the patient’s progress toward achieving the individualized objectives in the treatment plan.
(4)Treatment Plan Review: The permanent patient record shall document that the treatment plan is reviewed and modified continuously as needed and as clinically appropriate, consistent with the ASAM PPC 2R.
(5)Modifications: Changes in the patient’s treatment needs identified by the review process must be addressed by modifications in the treatment plan. Any modifications to the treatment plan shall be made in conjunction with the patient.
(6)Treatment Summary: No later than 30 days after the last service contact, the program shall document in the permanent patient record a summary describing the reason for discharge, consistent with the ASAM PPC 2R, and the patient’s progress toward the treatment objectives.
(7)Discharge Plan: Upon successful completion or planned interruption of the treatment services, the treatment staff and patient shall jointly develop a discharge plan. The discharge plan shall include a relapse prevention plan, which has been jointly developed by the counselor and patient.
Rule 415-020-0035 — Treatment Planning and Documentation of Treatment Progress,