Attachment J-6 Vendor Clinical Staffing Form.pdf
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- Attached to
- Residential Drug Treatment Services (FY 2024)
- Solicitation number
- 9594CS24R0022
About this file
This document contains an attachment and related federal contract opportunity. The attachment is a vendor clinical staffing form used to document treatment progress for patients in residential drug treatment. It requires information on the patient, assigned case manager, treatment plan completion, assessment completion, medication compliance, and aftercare planning.
The associated federal contract opportunity is a solicitation for residential drug treatment services with the objective of stabilizing substance use disorders in offenders, promoting supervision compliance, reducing recidivism, and facilitating community reintegration. The contractor must provide treatment at a facility within 30 miles of Washington, D.C. for up to 30 days, with potential extensions. Services include substance use disorder treatment for men and women. The awarding agency is the Court Services and Offender Supervision Agency.
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Text version
Attachment J-6: Vendor Clinical Staffing Form
Date: __________________ Vendor Name/Location: ___________________________
Patient Name: ____________________Assigned Case Manager: _________________
PDID #: __________ Arrival Date: __________ Referring Source: ________________
Projected Discharge Date: _____________ Date of next scheduled visit: ___________
CSO’s name & contact#: __________________________________________________
Attendees:
Was the Clinical Staffing conducted as scheduled? Yes ______ No ______ (give reason)
Treatment Plan completed within 2-days? Yes_____ No______
ASI completed within 2-days? Yes _____ No ______
Progress notes completed daily? Yes _______ No ______
Treatment Goals identified? Yes _____ No _____
Any clinical progress/changes observed/documented since first or most recent staffing?
Yes _____ No ______ N/A _______
Any existing significant behaviors (observed or reported)? Yes _____ (describe below) No _____
Identify Patient’s strength(s):
Identify Patient’s Limitations:
Identify Patient’s level of functioning:
Identify any changes in level of motivation/readiness to change and check the appropriate stage:
Pre-contemplation Contemplation Preparation Action Maintenance Relapse
Does the Patient have an Aftercare Plan (with his/her input)), to include community support services? Yes _____ No _____ (give reason) ________________________________________
Does the Patient have a Discharge Summary completed (1-days) prior to discharge?
Yes ______ No ______ (give reason) N/A (3-10-days Medically Managed)
Is Patient compliant with programming activities? Yes ______ No _____ (describe below)
Medication:
Is the Patient on any medications (psychotropic or other types)? Yes ______ No ______
If yes, is this information documented properly in the treatment file? Yes ______ No _______ (give reason)
Does the Patient take his/her medications as prescribed? Yes _____ No _____ (give reason)
Is the Patient linked in the community for medical and/or mental health services?
Yes ______ (indicate where below) No ______ (give reason) N/A _____
File details come from the government source that posted it. Updated .