Clinical Progress Note



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SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS NOTE (SOAP FORMAT) DSM-5 DIAGNOSIS(ES) Opioid Use Disorder: Severe ASAM DIMENSION(S) Please choose the dimension(s) that this note addresses Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 SOAP FORMAT S - Subjective: Patient statements that capture the theme of the session.. Medi-Cal ID: John Doe 123-45-6789 Treatment Agency: Healing SUD Treatment Center Progress Note Template Revised 04/13/2016 SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS NOTE (GIRP FORMAT) DSM-5 DIAGNOSIS(ES) Opioid Use Disorder: Severe ASAM DIMENSION(S) Please choose the dimension(s) that this note addresses Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 GIRP FORMAT G - Goal Patient’s current focus and/or short-term goal, based on the assessment and treatment plan.. Medi-Cal ID: John Doe 123-45-6789 Treatment Agency: Healing SUD Treatment Center Progress Note Template Revised 04/13/2016 SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS NOTE (SIRP FORMAT) DSM-5 DIAGNOSIS(ES) Opioid Use Disorder: Severe ASAM DIMENSION(S) Please choose the dimension(s) that this note addresses Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 SIRP FORMAT S - Situation Patient’s presenting situation at the beginning of intervention.. Medi-Cal ID: John Doe 123-45-6789 Treatment Agency: Healing SUD Treatment Center Progress Note Template Revised 04/13/2016 SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS NOTE (BIRP FORMAT) DSM-5 DIAGNOSIS(ES) Opioid Use Disorder: Severe ASAM DIMENSION(S) Please choose the dimension(s) that this note addresses Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 BIRP FORMAT B - Behavior Patient statements that capture the theme of the session and provider observations of the patient..




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