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Date
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Concurent Case Review
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Treatment TEAM
• • •
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Dimension 1 WITHDRAWAL POTENTIAL Condition Symptoms
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Dimension 1 Acute Withdrawal and Intoxication
• • •
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Dimension 1 risk rating
• • •
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Dimension 1 Continued Stay Criterion
• • •
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COWS SCORE
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Resting Pulse Rate: beats/minute
• • •
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Sweating: over past 1/2 hour not accounted for by room temperature or patient activity.
• • •
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What symptoms are they self reporting? Has the nurse done a COWS or CIWA score recently-what is the rating? Check the Self-repor
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Narrative
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Dimension 2 BIO MED Condition Symptoms
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Temperature:
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Notes
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Respirations:
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O2 Sat: ___ %
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BP:
/
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Pulse:
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Height:
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Weight:
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Pain(1-10)
/
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Head Circumference(in)
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Narrative
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Smoking Status
• • •
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Dimension 2 risk rating
• • •
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Dimension 2 Continued Stay Criterion
• • •
|
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Narrative
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Focus
• • •
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Relapse Proneness Problems
• • •
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Relapse proneness explanation (if needed)
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Dimension 3 Emotional, Behavioral, or Cognitive Conditions and Complications
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judgement
• • •
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cognitive functioning
• • •
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oriented
• • •
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Thought process
• • •
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Affect
• • •
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mood
• • •
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Behaviors
• • •
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SI/HI/SIB
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auditory or visual hallucinations
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Barriers to treatment
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Dimension 3 risk rating
• • •
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Dimension 3 Continued Stay Criterion
• • •
|
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Narrative
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Dimension 4 Readiness to Change
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Motivation/Engagement in treatment
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Compliant?
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What is the client's readiness to change?
• • •
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Participation in group
• • •
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Focus
• • •
|
|
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Treatment resistance problems
• • •
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Explanation of treatment resistance problems
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Dimension 4 risk rating
• • •
|
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Dimension 4 Continued Stay Criterion
• • •
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Dimension 4 Narrative
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Dimension 5 Relapse, Continued Use, or Continued Problem Potential
|
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12 step participation (NA/CR/AA/etc)
• • •
|
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Explanation of impulsivity problems
|
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cravings scale
• • •
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Known triggers:
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Known coping skills:
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comments:
|
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Dimension 5 risk rating
• • •
|
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Dimension 5 Continued Stay Criterion
• • •
|
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Dimension 5 Narrative Longest period of recovery, including how it was achieved:
|
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Dimension 6 Recovery/Living Environment
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family involvement
• • •
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family circumstances
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Sponsor relationship
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Supports
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living arrangements
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employment/financial arrangements
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Dimension 6 risk rating
• • •
|
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Dimension 6 Continued Stay Criterion
• • •
|
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Dimension 6 Narrative - Describe barriers to living and recovery enviroment
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Discharge plan
|
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how long do you plan to stay on treatment
|
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plan for aftercare
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living arrangements for after treatment
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current needs
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Other problems
• • •
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treatment goals
|
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progress
|
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recommendations
|
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reommended level of care
• • •
|
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Participant(s)
• • •
|
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Participants
|
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Staff Signature
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