Attachment J-8 Vendor Clinical Staffing Form.pdf
PDF 159 KB Posted
- Attached to
- Residential Drug Treatment Services
- Solicitation number
- 9594CS26Q0055
About this file
This is a clinical staffing form template used by vendors to document patient treatment and progress during clinical staffing meetings. The form captures essential administrative information including the date, vendor name/location, patient demographics (name, PDID #, arrival date, discharge date), assigned case manager, and clinical staffing organizer (CSO) contact details.
The form evaluates compliance with treatment requirements and clinical documentation standards, including whether clinical staffing occurred as scheduled, treatment plans were completed within two days, Addiction Severity Index (ASI) assessments were completed within two days, and progress notes were documented daily. It requires documentation of treatment goals, clinical progress or changes since the last staffing, identified significant behaviors, patient strengths, and limitations. The form also assesses patient functioning level, motivation/readiness to change using stages of change (pre-contemplation through relapse), and whether an aftercare plan with community support services has been developed with patient input. Additional sections address discharge summary completion requirements, patient compliance with programming activities, medication management (including psychotropic medications), proper documentation in the treatment file, medication adherence, and community linkages for medical and mental health services. Each section provides yes/no response options with space for explanatory notes or reasons when responses are negative.
View the file
Other files
Show all 21
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment J-8: 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 .