In general, the following are major components of the clinical records: 

A.     Request for Admission/Pre-admission Information:
 This section of the client record is provided by the referral sources. This section will contain the initial
request for admission, a physical examination within the last thirty (30) days, a brief client history and an assessment as to the need for inpatient treatment. This information must be received by Intertribal five (5)
 days before a client  may be admitted for treatment.

B.     Intake and Initial Treatment Plan: This section of the record contains pertinent information for
admission. This includes statistical data, referral source, emergency contact person, immediate medical
and dietary needs. This will be completed upon admission by designated staff on duty. The assigned
 case counselor or the program director will review the initial treatment plan, within 72 hours of
 admission. This will be documented by the program director's signature, which shall include credentials
 and the date.

C.     Client Orientation to Program Information: This section of the record includes items which help orient
 the client to the program and provides documentation of the orientation. This information includes:
treatment philosophy, nature and goals of the program, client rights and grievance procedure.
This also includes client responsibilities, hours of service, rules of conduct, house rules, infractions leading
 to discharge, fee schedule if applicable, and explanation of the collection of data, and staff responsibilities,
 and an overall explanation of the phases of treatment and other information specific to the program.
Client orientation is completed upon admission by designated staff on duty and documented by having the
client sign a "documentation of understanding" which becomes a permanent part of the client record.

D.    ASI Social History: The social history is the organization of necessary and sufficient information upon
 which to make clinical judgements. The social history includes specific information
 about identification/demographics, medical, cultural/family/social, educational, and vocational. This
also includes psychological, psychiatric, spiritual, nutritional, and legal domains as well as the
chemical history of the client. The social history will also include the SASSI #3, MAST (Michigan
Alcohol Screening Test). The social history will be completed with five (5) days of admission by the client
and reviewed with the client by the primary counselor within fifteen (15) days of admission.

E.     ASI Assessment: The assessment is a summary of each of the domain areas covered in the social history
 and how they have been affected by substance usage. The assessment will also include statements of problems
 in life areas, which may not be the direct result of the client's substance usage. The assessment will include
 a statement specifically stating the client's personal strengths and needs, and a statement relating to the
need for treatment. The assessment will be reviewed by the client, primary counselor, and program
director, which will then document his/her assessment which completes the case management
process. Assessment and Case Management are to be completed within (5) five to (7) seven days of admission.

F.      ASI Individualized Treatment Plan: The individualized treatment plan is the means by which the delivery
 of services and the recovery of the client are planned and monitored. The individualized treatment plan
is developed through the case management process and client input based on the assessment of client needs.
The individualized treatment plan must include the following:      

·        a) Specific individual goals and objectives;             

·        b) Methods of attaining objectives; 

·        c) The frequency of treatment strategies; 

·        d) A timeline for attaining objectives/methods; 

·        e) Specific descriptive and behavioral language; and 

·        f) Documentation of a staffing process and client input. 

The intention of the individualized treatment plan is to identify goals and objectives. It is recognized that in
some instances the family unit as an entity may be the focus of treatment strategies and activities. As such,
the treatment plan may identify family objectives in addition to key individual objectives. 

The individual treatment plan must be developed within fourteen (14) days of admission and reviewed at
seven (7) day intervals. Exceptions to these guidelines must be justified and documented in progress notes.
 Each treatment plan will include a minimum of two (2) goals, one of which is abstinence from all mood
altering chemicals not prescribed by a physician.                             

 G.  Progress Notes: Progress notes are clinical reports of the delivery of        

Services to clients in relation to the individual treatment plan. The following is   the acceptable format for
daily, weekly, and group/individual sessions; 

 Subjective - Client quotes or paraphrases; 

 Objective - Focus of therapy since last charting, including treatment

      plan objectives attempted or completed in timeframe; 

 Assessment - Assessed areas of progress,  problems and behaviors; 

  Plan - Action plan for client, counselor and identify major treatment

            plan revisions.                

Each category need’s to be no more than one (1) or two (2) sentences in length.  Weekly group activity notes
 do not need to follow the SOAP method.  Weekly entries will be a short statement regarding progress and participation.  Significant clinical event need to be charted as they occur such as threats to leave, suicidal gestures, threatened or actualized harm to others, sexual contact issues, chemical usage, actions which place clients on a discharge notice and actions that necessitate medical attention.  

G.    Progress Report.  This serves to summarizes treatment services while the  

client is in treatment and to monitor client progress.   

H.    Aftercare Plan. This serves as a plan which the client will use to continue     

their recovery process after discharge.  The Aftercare Plan will be developed by the primary counselor
and client five (5) days prior to discharge.  

I.   Discharge Summary. This serves to summarize treatment services and client progress while the client was actively participating in the treatment program.  The Discharge Summary will be completed by the primary counselor within ten (10) days following discharge.