ASAM Assessment and Medical Justification For SUD

ASAM Assessment: Identifying Information: [document patient's name, age, gender, and other identifying details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Presenting Problem: [describe the patient's current issues, reasons for seeking treatment, and any immediate concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Substance Use History: [detail the patient's history of substance use, including types of substances used, duration, frequency, and patterns of use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medical History: [document the patient's past and current medical conditions, hospitalizations, surgeries, and any relevant medical treatments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Psychiatric History: [describe the patient's psychiatric history, including any diagnoses, treatments, hospitalizations, and current mental health status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family History: [detail the patient's family history of substance use, mental health issues, and any other relevant medical conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Social History: [document the patient's social history, including living situation, employment status, education, legal issues, and social support] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Dimension 1: Acute Intoxication and/or Withdrawal Potential: [assess the patient's risk of acute intoxication or withdrawal, including any recent use and withdrawal symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Dimension 2: Biomedical Conditions and Complications: [describe any biomedical conditions or complications that may affect the patient's treatment and recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications: [assess the patient's emotional, behavioral, or cognitive conditions that may impact treatment and recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Dimension 4: Readiness to Change: [evaluate the patient's readiness and motivation to change their substance use behavior] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Dimension 5: Relapse, Continued Use, or Continued Problem Potential: [assess the patient's risk of relapse or continued substance use and any factors that may contribute to this risk] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Dimension 6: Recovery/Living Environment: [describe the patient's recovery environment, including living situation, social support, and any potential barriers to recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Assessment Summary: [summarize the key findings from the assessment, including the patient's strengths, challenges, and any immediate needs] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Treatment Plan: [outline the proposed treatment plan, including goals, interventions, and any referrals to other services or providers] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)