Wonder Works Health

A dedicated substance abuse treatment program conveniently located in the Federal Hill area of
Baltimore City. We specialize in Intensive Outpatient (IOP) and Partial Hospitalization Program
(PHP) services, providing comprehensive care to individuals seeking recovery.

Our programs are designed to meet the needs of our clients with flexibility and commitment. Our
IOP groups meet four days a week, offering 2.5 hours of focused sessions each day/ For those
requiring more intensive support, our PHP groups are available seven days a week, with 6-hour
daily sessions. Please take note that we exclusively serve individuals with Medicaid insurance.

Visit us at 1124 S Charles Street, Baltimore, Md 21230, to learn more about how we can
support you or our loved one in achieving lasting recovery.

TERMINOLOGIES
- Methadone & Suboxone
- Clinician abbreviations & meaning
- PHP
- IOP

Intake Assessments
Initial intake assessments are done via phone call by the Virtual Assistant where in the phone
call conversation would be recorded on the WellReceived App (communicator app). Not all
intake assessment questions will be answered through the initial intake assessment hence the
documenter may have to call to continue the intake assessment.

The documenter will call the housing staff and do the intake assessment on the patient (for
questions that were not answered in the initial intake assessment).

Main information needed from the patient:

● Full name
● Date of birth
● Social Security Number
● Drug of choice
● The last time they used their drug of choice
● How often do they use
● How much do they use
Intake Assessment Questions
Questions to gather required client Information:
1. What is your full name?
2. What is your date of birth?
3. What is your gender?
4. What is your address?
5. What is your phone number?
6. What is your email address?

**Presenting Problem**
7. What is the primary substance you use?
8. Are there any secondary substances you use?
9. How long have you been using these substances?
10. How frequently and how much do you use these substances?
11. When was the last time you used?
12. What method do you use to take these substances?
13. Who taught you how to use these substances?

**Medication**
14. Are you currently taking any medications?
15. What is the name of the medication?
16. What is the dosage and frequency?

**Sobriety History**
17. What is the longest time you have been sober? - because if 2 months or something, we
put on diff level; level dependent on how long since they last used. - PHP
18. Have you experienced any recent relapses? If so, when and where?

**Support and Motivation**

19. Are you interested in attending 12-step meetings?
20. Why do you want to seek treatment?
21. How many children do you have? How many are living?

**Emergency Contact**
22. What is the name of your emergency contact?
23. What is their relationship to you?
24. What is their phone number?

**Referral Information**
25. Who referred you to our program?
26. What is the contact information for the referral source?
27. What is the reason for your referral?
**Advanced Directives**
28. Do you have an advanced directive? If so, what is the name and phone number of the
person listed?

**Triggers**
29. What are your identified triggers for substance use?

**Medical Information**
30. Do you have any allergies?
31. Have you tested positive for any diseases (e.g., hepatitis)?
32. Do you have a primary care physician?
33. Do you have any high sugar levels or need testing for diabetes?
34. When was your last physical exam?
35. What is your current weight and height?

**Mental Health**
36. Do you have any mental health diagnoses?
37. Have you ever been hospitalized for psychiatric reasons? If so, when and why?
38. Have you experienced any suicidal thoughts or attempts? If so, when?
39. Have you ever overdosed? If so, how many times and when?

**Suicide Background**
40. Are you currently experiencing any suicidal or homicidal ideation, or self-injurious
behavior?

**Family Background**
41. How many siblings do you have?
42. How many are incarcerated?
43. What is your position in the family (e.g., youngest, oldest)?
44. What is your marital status?
45. Do you have any children? If so, what are their ages and statuses?

**Personal Background**
46. Where were you born?
47. What is your current address?

**Financial Information**
48. Do you have any income?
49. Do you have medical insurance? If so, what type?
50. Are you receiving food stamps?

**Treatment History**
51. What was the reason for leaving your last treatment program?
**Cravings**
52. Do you experience cravings?
53. Are you experiencing any cravings right now?
54. (If the patient is craving) On a scale of 1 to 10, how strong are your cravings?

**Activities to Stay Sober**

55. What activities do you currently engage in to stay sober?

**Medical Conditions**
56. Do you have any medical conditions such as seizures?

Documenter Credentials
Google Account:
Username: Aceephas@wwhealthservices
Password: =J>DAHumWThC4bL>

ICANotes: https://ehr.icanotes.com/
Username: acephaswwwh
Password: Zinc-Sink54

ICANOTES
Website: https://ehr.icanotes.com/
ICANotes is the platform where all patient information is stored and documented.
❗Important❗
● New intake patient charts should be created within 24 hours after the patient has been
taken in.

Welcome to ICANotes!
Login credentials will be created by Ms. Malika Shabazz

Inside ICANotes

Where we can search the patient name to pull up their records.

Making a New Chart
Click on the “Make a New Chart” button to start creating a new chart for a new intake patient.

This “Create New Patient” tab will appear after clicking on “Make a New Chart”
Input the new patient details. Then click “Create”.
● Date format: mm/dd/yyyy

After clicking “Create”, you will be redirected to this page where you need to fill out the following.
Patient information notes:
● Sex: We rarely choose “U” (unidentified)
● Gender: Choose either woman or man. Take note that we do not take children in.

○
● Address: If the patient is homeless, ask the patient of their address on their license/ID.
○ What’s your address on your license or ID?
○ If there is no address at all, tick the “Homeless” box and type in “none” for all the
boxes that need information regarding the patient's address.

● Home Phone: Type in 10 digit number and the system will automatically format the
number you just typed in.
● SSN #: Social Security Number is required (needed for billing purposes and checking
insurance)
 ● Ethnicity: Always choose “Not Hispanic or Latino”
● Native American: Usually “N”
● Veteran: Usually “N”
● Disability: Input “none” if they don’t have any among the choices.

● Employment Status: Most patients we take are unemployed.

● Annual Household Income: Usually 0 - 24,999
● School or Employer: Any school name they have attended. Otherwise, input “none”.
● Grade: choose “n/a” if none.
● Release of Info: We always have a release of info from the intake packet given to the
patient. Always select “A (Appropriate Release of Info on File)
○ If the patient came in on a prior date from the date you are currently setting up
their new chart, we need to change the date to when the patient came in.

● Adv. Dir. (Advance Directives):

○ Do you have someone that would be able to make decisions for you in the event
that you cannot make the decisions for yourself?
○ Person could be their emergency contact.

Click on “Generate ID#” to generate the Unique Patient ID.

 ● Alt. Patient ID & Room - no need to fill out

Scroll down on the bottom of the page on “Assigned Providers”

Select on “Select a Clinician”

This tab will appear where we have to choose clinicians. We need to assign the three providers
below.
We assign 1 provider at a time by clicking their name. Since we have to assign 3 of them at a
time, we repeat the procedure from clicking on “Select a Clinician”.

What it looks like when the three providers are assigned.

A clinical supervisor must also be assigned. Untick the box for “Exclude Office & Admin Users”.

Assign Ms. Rose Washington, LCADC as she is our Clinical Supervisor who needs to sign all
notes.

Also, add Ms. Malika Shabazz for her to oversee what is going on in the system. She will cross
check this with the submitted EOD report.

For the “Where Seen” option, click on “Add New Location” and select “Wonder Works LLC”
Next, click on the “CONTINUE to Initial or Complete Exam”

You will be directed to the page below after clicking on the “CONTINUE to Initial or Complete
Exam”
Note:
If the VA completed the new chart for the new intake patient but did not click on “CONTINUE to
Initial or Complete Exam” and just clicked on either of the 2 options below, look up the patient’s
name.
Searching for the patient’s name

Select your patient on the list

You will be directed to the patient’s Chart Face page. Click on “Complete Assessment” to
proceed on doing the assessment.
You will then be brought back to the page below.
❗Always check the Clinician assigned. It’s supposed to be Angela Cephas all the
time.❗
Updating Demographics
If, upon rechecking a patient's demographic records, you find missing information, take note of
the following while updating the demographics:
● If they have no Home Phone nor Cell Phone, just type in zeros 0
● If information is missing for options that need text (non numerical figures), just type in
“none” or select “unknown” from the drop down.
● If information is missing for “Ethnicity”, choose “Not Hispanic or Latino” as the safest
answer.
● If Family Size is missing, do not put 1 as the person may have kids or other family
members.
● Employment status - 9/10 patient is unemployed (Annual Household Income: 0-24,999)
● Grade - 9/10 patient is a high school graduate
● Do not click anything for this part:

Note: You can always recheck the initial intake assessment for the missing information.

Completing the Assessments - Initial Evaluation

Example of a completed assessment: Initial Assessment for PHP or IOP (The New Clinical
Supervisor Rose Washington).pdf

The complete evaluation used on this part of the module is from the link above
To complete the initial evaluation, you have to work your way through the tabs from “Hist.
Present Illness” to “Finish Initial”.

❗Follow the flow of this procedure as this will complete the evaluation for either
IOP/PHP Intake❗

Hist. Present Illnesses

1. History: Ms. doe is a single Non-Hispanic 60-year-old woman. Her chief complaint is,
“INSERT THE REASON THE CLIENT IS SEEKING TREATMENT (Why do you want to
seek treatment?)”

Navigate through the left side of the webpage.

You have to work from top to bottom to complete the evaluation.

Looking at the example evaluation,

Client has Symptoms of:

2. Click on “Client has Symptoms of:” followed by clicking on “Chemical Dependence” then
“Info Received From”. Type in the patient’s name since the patient is the interviewee.
Substance Used
3. Substances Used
Click “Substances Used:”. Next, select the patient’s substance of choice.

Helpful questions used from the assessment:

Questions:
● What is the primary substance you use?
● Are there any secondary substances you use?
Pattern of Use
4. Pattern of Use
As per example, click on “Increased Amounts” - safest option to click since 9/10 of our patients
are drug users.
Followed by selecting “Use to Avoid”
Other Patterns: The following numbers indicated per pattern are the number assigned per
question from the intake assessment questions. This will help you identify which questions to
ask to know whether that pattern is related to the patient.

Most Common Patterns: (and the questions from the intake assessment that can be helpful)
● Large Amounts
○ How long have you been using these substances?
● Excessive Time Spent
○ How frequently and how much do you use these substances?
● Craving
○ Do you experience cravings?
○ Are you experiencing any cravings right now?
○ On a scale of 1 to 10, how strong are your cravings?
● Failure to Fulfill

Patterns that can be modified:

● Craving
● Persistent Problems

Use Severity: How often are these people really using? How many symptoms are you
experiencing?

WWH sticks to Mild Severity.

❗Mild: 2-3 Symptoms

Trigger for Use
5. After filling out the necessary information for “Pattern of Use”, click on “Triggers for Use”

Main question: What are your triggers? (sample questions/answers are provided)
● Exposure to Substance
○ Is your craving triggered when you are around the substance?
● Strong Association
○ Do your friends have a very strong association with people who sell drugs?
● Good Times
○ Do thoughts of having a good time trigger your cravings?
● Peer Pressure
○ Are you influenced by peer pressure?
● Stress
○ Work
○ Home
■ Is there too much going on at home/work?
○ Relationship
■ Is your relationship causing you stress?
○ Financial
■ Are financial difficulties contributing to your urge to use?
○ Legal
■ Are legal issues affecting your decisions?
○ Medical
■ Are health issues making you consider using?

Amount Used
6. After selecting the necessary options for “Trigger for Use”, click on “Amount Used”.
● How frequently and how much do you use these substances?
Note:
Make sure to add the necessary numerical figure on the highlighted below.
If the patient provides an amount of how much they spend for drugs, do not forget to input the
amount they mention on the highlighted below.
Route of Administration
7. Next, click on “Route of Administration”
● What method do you use to take these substances?

Notes:
● Nose - snorting
● Inhalation - breathing by mouth

Frequency of Use
8. Next, click on “Frequency of Use”
● How frequently do you use these substances?
❗Note: Instead of “few times per week”, try to get a figure from the patient. ❗

Longest Abstinence
9. Next, click on “Longest Abstinence”.
The last time the patient has been clean/sober.
● What is the longest time you have been sober?

❗Remember to input the numerical figures.❗

Length of Use
10. Next, click on “Length of Use”.
● Question 9 (You can also ask at what age the patient started using the said substances)
❗Make sure the math adds up. Context clues will be most helpful for this part. The
age of the patient is also given below the patient’s name.❗
Last Used
11. Next, click on “Last Used”.
● When was the last time you used?
❗Remember to input the numerical figures.❗

Past Psych. Hist.

From Hist. Present Illness tab, click on the “Past Psych. Hist.” tab to start creating the past
psychiatric history evaluation.
After clicking on the tab, you will see this page.

1. Start with clicking on “Info Received From”, then click on “Name” (if the information came
from the patient so that their name would appear) (see below)
 2. Next, click on “Hospitalizations?”
● Have you ever been hospitalized for psychiatric reasons? If so, where, when and why?
Note: If the patient can’t recall the hospital, don’t click “City Hospital”

3. Next, click on “Outpatient Treatment”

● Question 27

Condition treated: select which condition the client has gotten treatment for (Mostly chemical
dependency but select the conditions mentioned by the client. Remember to revise the
sentences accordingly.)
Occurred at age: Select the option when the treatment occurred.
● Question 37 (Have you ever been hospitalized for psychiatric reasons? If so, when and
why?) would be helpful to get your answer.

Length of Episode: Select the option of the duration.

● Question 38 (How long did the treatment last?” or “How long did you have the treatment
for?”
❗Remember to input the numerical figures.❗

Medication Prescribed?
● Question 40 (Was medication prescribed to you?)
Note: If the client does not remember what was the medication prescribed, then just type in that
the client does not remember.
 4. Next, click on “Suicidal / Self Injurious”
● Question 38 (Have you ever been hospitalized for psychiatric reasons? If so, when and
why?)
Note:
● 9/10 is “Never” - Because WWH don’t take patients with current suicidal thoughts as
those people require a higher level of care.
● Since this is the Past Psychiatric History, clients may say they have had past suicidal
thoughts.

● ❗If the episode has been within 3 to 6 months, the past psychiatric history
must be recorded within the day. ❗(As the patient might have to be referred
to a in-patient mental health facility.)

5. Next, click on “Assaultive”

 ● Question 41 (Have you ever engaged in behaviors where you physically attacked or
assaulted someone else in the past?)

6. Next, click on “Acting Out”

● Question 42 (“Did you have any history of acting out behaviors like running away?”)
Select any acting out behavior if it has been mentioned by the client.
 7. Next, click on “Medication Compliance”
Note: You need to know if the patient has been prescribed medication and if they are complying
on taking said medication or not.
To know if they are taking any medication: Question 14 & 15 (Are you currently taking any
medications? What is the name of the medication?)

Question 16 “Are you compliant with your medication?”

❗If the patient is on prescribed medication, it is essential to know if they are

compliant on taking it. Indicate it on the evaluation. Click on “History of Non
Compliance”.❗
 8. Psychotropic Medication
● Question “When did you last take the medication?”
❗Remember to input the numerical figures.❗
For Current Dose: type in their dosage.
Effectiveness: We always put “Very Effective”

9. Prior Psych Disorder

● Question 38 (Do you have any mental health diagnoses?)
Medical Hist.
From Past Psych. Hist. tab, click on the “Medical Hist.” tab to start creating the medical history
evaluation.

After clicking on the tab, you will see this page.

 1. ADRs and Allerg/Intoler
● Question 32 (Do you have any allergies?)
If the client has allergies, just type in the information. No need to click on the options.
 2. Current Medication
● Questions 14, 15, 16 (Are you currently taking any medications? What is the name of the
medication? What is the dosage and frequency?)

If the client is currently on medications, just type in the information. No need to click on the
options.
❗Always ask for the dosages. We need to have the dosage on record.❗
Example

3. Hearing/Vision
● Question 18 (Are you currently experiencing any difficulties with your hearing or vision?”

4. Infection or Disease
● Question 19 (Have you recently been diagnosed with an infectious disease or been
exposed to someone with an infectious disease?)
Note: 9/10 is “None” - If the patient says they do have Tuberculosis (TB), report it to Ms. Malika)
 5. Pain
Click on the following:

Also, type in “Pain is 5 out of 10”

 6. Past Medical History
Question 36 (What is your past medical history? This includes any illnesses or surgeries you
have had in the past.)
Note: Just type in the Past Medical History. No need to click from the list.

7. Tobacco
When you click on the “Tobacco” option, the pop-out below will show up.
Social Hist.
From Medical Hist. tab, click on the “Social Hist.” tab to start creating the social history
evaluation.
After clicking on the tab, you will see this page.

1. Abuse/Neglect
Was Abused
Question 57 "Have you ever experienced any form of abuse, whether emotional, physical,
sexual, or verbal?"
Was Neglected
Question 58 "Have you ever experienced neglect in any of the following areas: education,
emotional support, medical care, physical care, or supervision?"

Began When

The rest of the options will let you create a narrative of the patient’s social history.
 2. Activities of Daily Living
Question 59 "What leisure activities are you currently engaged in or enjoying regularly?"
Note: You don’t need to indicate the frequency. Listing some of their leisure activities are
enough.
 3. Assistive Devices
Question 39 “Do you walk independently?” or "Do you use any assistive devices to help with
your daily activities or mobility?"
 4. Barriers to Treatment
Question 61 (Is there a reason why you can’t involve yourself into treatment?” or “Is there
something stopping you from getting treatment?)
Note:
● Do not select “Religious” because there might be a need to locate the pastor's name. =
Hassle

● You can stick to the community support related options - select “Cultural”
 5. Case Management Needs
Note:
● What do the patients need from WWH to help them handle their lives?
● Most common answer is financial and legal/criminal

Question 65 (What specific case management needs do you have at this time? "Could you
please share with me which of the following areas you feel you may need assistance with in
terms of case management: education, financial support, housing, occupational guidance, legal
or criminal matters, healthcare access, etc?)
 6. Children
Question 54 (Do you have any children? If so, how many and what are their ages and
statuses?)
Note: “(from previous relationship)” is the safest option.
 7. Coping Diversions
Note:
● These are activities that help the patient to cope when they are tempted to abuse a
substance.
● If the patient’s answer is not included in the options, you may just type it.
Question 69 (When you feel tempted to abuse substances, what coping mechanisms or
activities do you typically turn to?)
 8. Coping Strengths
Question 70 (When you feel tempted to use, what strengths do you rely on to cope with that
temptation?)
 9. Criminal Justice History
Question 46 Have you been arrested or incarcerated?
Required information:
● Number of arrests
● Legal status
● Violent behavior
 10. Cultural and Religious
Required information from:
● Religious Identification
● Cultural Identification
● Cultural Issues
● Sexual Identification
 11. Educational History
Question 7 (What is your educational background?)
Note: Type in their school/university name.
 12. Employment History
Question 8 (Can you tell me about your employment history?)
Note: If the patient’s answer is not included in the options, you may just type it.
 13. Family of Choice
Note: Where the patient’s family of choice centers to.
Question: "Who would you consider to be your chosen family or support network?"

Family Stresses
Question: "Can you describe any sources of stress within your family or close relationships that
are currently affecting you?"
 14. Family of Origin
Required information from:
● Born in
● Raised by
● Currently lives with..
● Birth order
● Primary Family Consist of
 15. Financial Status
Note: 9/10 the patient has no steady income.

16. Gender/Sexual Identity

Question: "Can you describe how you identify in relation to your gender and sexual orientation?"

17. Housing
Note:
● To identify the patient’s housing situation.
● If the patient’s answer is not included in the options, you may just type it.
Question: "Could you tell me about your current living situation or housing arrangements?" | “Do
you live alone?”
 18. Military History
Question: "Can you provide details about your military history, including your current status, type
of service, your experiences during service, the type of discharge you received, and whether
you are eligible for veterans' benefits?"
 19. Personal Goal(s)
Question: "What are your personal goals that you hope to achieve through this program?"
Note: If the patient’s answer is not included in the options, you may just type it.

20. SNAP
Notes: Use context clues to provide answers as some information may have already been
asked earlier in the evaluation that would give you the answers you need for this part.
Required information from:
● STRENGTHS

● NEEDS

● ABILITIES

● PREFERENCES (Treatment) - click on “Group Therapy” and “Individual Therapy”

 21. Support System
Question: “Do you have a support system? If so, who is/are your support system?”

22. Transportation
Question: "What transportation arrangements will you rely on to attend your appointments?"
 23. Trauma History
Question: "Could you please share with me any experiences you've had that you consider to be
traumatic?"
Notes:
● 9/10 “authorities were not notified”
● Don’t forget to remove “Details are as follows:”
Develop Hist.
From Social Hist. tab, click on the “Develop Hist.” tab to check the formulated information. (just
scroll a bit and recheck)

After clicking on the tab, you will see this page.

Fam MH Hist.
From Develop Hist. tab, click on the “FAM MH Hist.”
After clicking on the tab, you will see this page.

Note:
● Use context clues since the patient has already mentioned their present family
members.
● If the patient does not know, you can click on “unavailable”
Question: "Can you provide me with information about your family psychiatric history, did your
mother experience any abuse..?”
Mental Status Exam
From FAM MH Hist. tab, click on the “Mental Status Exam.”

After clicking on the tab, you will see this page.

Note:
● Since you are unable to physically observe the patient during the interview conducted
over the phone, complete the mental status exam by describing their emotions or
demeanor based on their tone of voice or expressions.
● Don’t click anything under “Mood:”
● For “Suicidality:” - you only have to consider if they have any suicidal thoughts at the
moment. Not the past.
Finish Initial
From Mental Status Exam tab, click on the “Finish Initial”

After clicking on the tab, you will see this page.

❗Please do not click on “Compile this Note”❗(Ms. Angela is the one who’s going to
compile them.)

1. Click on “Enter” on 3. Diagnosis. The below will pop out.

 2. Click ICD10
Note: This part is the process on how we bill the patient.

3. Scroll until you find “(F01-F99) Mental, Behavioral, and Neurodevelopmental disorders”
option then click it
4. Click on “(F10-F19) Mental, behavioral disorders due to psychoactive substance use”

5. For this part, it depends on which substance/s the patient says they are using. (but opt to
choose the option that says “unspecified, uncomplicated”)
When the three selections have been completed, this is what it looks like.

6. Click “Done”
7. After clicking done, you will be redirected back to this page.
8. Click on “Yes” so that the Diagnosis will be included in the note.
 9. Next, click on “Justify Level of Care” - we need to justify why they are here in the
program.

After clicking on the above, you will be directed to this page.

Note:
● This part is vital because this correlates to how we bill our patient which is also
dependent on when they last used their drug of choice as this will determine whether
they need to be in PHP or IOP
● The table below displays various levels of care, each associated with different billing
rates for the patient.
Outpatient Program (OP) Can last 1 year to 3 years 1 hour per session

Intensive Outpatient (IOP) Last use of drug of choice - 1 or 2 Can last from 1 month to 12 Group sessions - 4
months months (9 am to 11:45 am)

Partial Hospitalization Program Last use of drug of choice - 1 or 2 Can last up to 2 to 8 weeks 8 am to 3:30 pm
(PHP) weeks depending on the patient’s
progress

Residential treatment

10. Select the level of care the patient is qualified for and select the appropriate reason why.
11. Afterwards, click on “back”

12. And click on “Suicide/Violence Risk Assessment”

You will be directed to this page after clicking.

13. Identify the “Current Risk Factors”

 14. Next, click on “Violence Risk” and identify the level of risk.

Note: Remove the “Very Low” from the text.

Then click “back” to input the length of the session.

15. Input the length of session

 16. Select the “Code”

Choose the Behavioral Health Assessment

Note: Although the option below indicates 15 minutes, which differs from what we entered for
the 'Length of session,' this is acceptable because we can only bill the patient for 15 minutes.
Next, select the PHP option. Afterwards, click Done.

❗Never click on the “Teleheath Session”❗

As all of the prior procedures were autosaved, you can go back to the patient's Chart face.
You will see this “Unfinished Note”
Go back to the “Work Areas”

17. Compiling the note 1:59:26 / 2:46:13 - Ms. Angela to do

After a few mins from 1:59:26 / 2:46:13, an example call from a new intake patient

Chemical Dependency (6 ASAM Dimension) (INITIAL)

● Refer to the ASAM template: PHP Client ASAM Template instructions.pdf
● Example ASAM:
PHP ASAM Sample (More Detailed).pdf
● Components for ASAM
○ Rating
○ Clinical Narrative
○ Justification for PHP
● This is only the initial ASAM assessment because ASAM assessments are due every 7
to 10 days.
Note: Clinical Narratives and Justifications can be 3 - 4 sentences per paragraph.

From the Chart Face, click on “Chem Dependency (6 ASAM Dimensions)

After clicking on the above, you will be directed to this page where we will process the 6 ASAM
Dimensions.
ASAM Dimension 1: Intoxication / Withdrawal
Note:
● Rating is typically 2 (but rating 1 is also valid)
● The following questions needs to be answered:
○ Substance(s) of use
 ○ Path
○ Amount spend or amount used
○ Frequency
○ Date of Last Use
○ MAT (if applicable)
○ Sleep disruption
○ Withdrawal symptoms

Creating the Clinical Narrative:

Follow the template below; the numbers correspond to the number of question from the intake
assessment questionnaire. (You can use ChatGPT to put everything together that will fulfill the
required information for this dimension. Also, make sure the text is clear and there are no
unnecessary symbols)

Things to consider for Dimension 1:

The client’s primary drug of use is What is the primary substance you use?, a **insert what type
of drug**, with a reported consumption of How frequently and how much do you use these
substances?, costing approximately How frequently and how much do you use these
substances?. The client began using What is the primary substance you use? at the age of 9.
(Do you experience cravings? Are you experiencing any cravings right now? On a scale of 1 to
10, how strong are your cravings?)
Despite reporting no current cravings (0 on a scale of 1 to 10), Question: How is your sleep
pattern? The client experiences significant sleep disruptions, characterized by periods where
they can “sleep for days.” This pattern suggests potential withdrawal symptoms or side effects
related to synthetic cannabinoid use.

Example Clinical Narrative:

Creating the Justification for PHP: Essential to use ChatGPT for this part.
Type in the prompt : “I need a justification for a substance abuse partial hospitalization program
for “Mr/Mrs. Client Name” using the following prompt *insert clinical narrative *. Please place the
following justification in paragraph form.

Example:
ASAM Dimension 2: Biomedical Conditions/Complications
Note:
● Rating is 2
● The following information is required:
○ Allergies
○ Adverse Drug Reactions
○ At risk for falls
○ TB positive
○ History of seizures
○ PCP?
○ Medical diagnoses ex. Hypertension
○ Last physical
○ Medication prescribed and taking
○ Medication last taken

Creating the Clinical Narrative:

Create the clinical narrative following the order of the things to consider for this dimension. (You
can use ChatGPT to put everything together that will fulfill the required information for this
dimension. Also, make sure the text is clear and there are no unnecessary symbols).

You may use the following prompt on ChatGPT:

“Please put the following information in paragraph form for Mr.Client’s past biomedical
conditions/complications: *insert the question & answer for ChatGPT to use*”

Things to consider for Dimension 2:

Helpful questions from the assessment:

● Do you have any allergies?
● Do you have any drug adversary actions? Like Does your body react badly to some
drugs?
● How is your balance?
● Do you have seizures?
● What medication are you currently on?
● Do you have a primary care provider?

❗Add the sentence below on the end of the clinical narrative❗

“During his time in the program, all primary care medical needs, including the management of
his *insert illness* and monitoring potential allergic reactions, will be overseen by an on-call
Nurse Practitioner (NP).
Creating the Justification for PHP: Essential to use ChatGPT for this part.
Type in the prompt :
“Please write Mr. McNair a justification for a substance abuse partial hospitalization program for
the following “prompt:client’s narrative” and please place the following justification in paragraph
form.”

Example Clinical Narrative:

ASAM Dimension 3: Emotional/Behavioral/Cognitive Conditions and

Complications
Note:
● Rating is 2
● The following information is required:
○ Diagnosed MH ex. Bipolar
○ Inpatient hospitalization
○ Age
○ Where if known
○ For what ex. Mood regulation
○ Suicide attempts
○ How old or year
○ Current suicidal ideation’s
○ Homicidal ideation
○ Self injurious behaviors
○ Previous/current prescribed medication
○ Seen out pt counselor while not in treatment?
○ Who
○ How long
○ Overdose
○ When or at what age

Creating the Clinical Narrative:

Create the clinical narrative following the order of the things to consider for this dimension. (You
can use ChatGPT to put everything together that will fulfill the required information for this
dimension. Also, make sure the text is clear and there are no unnecessary symbols).

You may use the following prompt on ChatGPT:

“Please put the following information in paragraph form for Mr.Client’s past
emotional/behavioral/cognitive conditions and complications: *insert the question & answer for
ChatGPT to use*”

Things to consider for Dimension 3:

Helpful questions from the assessment:

● Do you have any mental health diagnoses?
● Have you ever been hospitalized for psychiatric reasons? If so, where, when and why?
● Have you been taking any medications to help your mental health? *If not, how about
any mental health interventions ?

Example Clinical Narrative:

Creating the Justification for PHP: Essential to use ChatGPT for this part.
Type in the prompt :
“Please write Mr. McNair a justification for a substance abuse partial hospitalization program for
the following “prompt:client’s narrative” and please place the following justification in paragraph
form of 3-4 sentences.

❗Add the sentence below on the end of Justification for PHP❗

“All mental health treatment will be managed by All American while in treatment.”
ASAM Dimension 4: Treatment Acceptance/Resistance
● Rating is 2
● The following information is required:
○ Initial ASAM
○ Use quotes
○ Support while in recovery and treatment
○ Longest period of sobriety and what were they doing ex. Working or working 12
steps
○ Stage of change
○ Follow up
○ Motivation
○ Support
○ Attending group on time
○ Participation level
○ Following program rules
○ Stage of change

Things to consider for Dimension 4:

Helpful questions from the assessment:

● What is your address? (to know whether the client is homeless)
● Why do you want to seek treatment? (to know what their motivation for treatment is)
insert the patient’s answer in quotation marks.
● What gets away in your sobriety?
● What is the longest time you have been sober?
● Do you have support from family and friends?

You may use the following prompt on ChatGPT:

“Please put the following information in paragraph form for Mr.Client’s treatment acceptance:
*insert the question & answer for ChatGPT to use*”

Example Clinical Narrative:

Creating the Justification for PHP: Essential to use ChatGPT for this part.
Type in the prompt :
“Please write Mr. McNair a justification for a substance abuse partial hospitalization program for
the following “prompt:client’s narrative” and please place the following justification in paragraph
form.”

ASAM Dimension 5: Relapse Potential

● Rating is 2
● The following information is required:
○ Name of previous treatment and whether they completed
○ If left, why
○ Triggers
○ Plan to address triggers and relapses

Things to consider for Dimension 5:

Helpful questions from the assessment:

● What are your identified triggers for substance use?
● On a scale of 1-10 how likely are you to relapse?
● What are some coping skills you have to avoid and prevent a relapse?
● Who referred you to our program?
● What programs have you attended in the past and why did you leave?

You may use the following prompt on ChatGPT:

“Please put the following information in paragraph form for Mr.Client’s relapse potential risk:
*insert the question & answer for ChatGPT to use*”

Example Clinical Narrative:

Creating the Justification for PHP: Essential to use ChatGPT for this part.
Type in the prompt :
“Please write Mr. McNair a justification for a substance abuse partial hospitalization program for
the following “prompt:client’s narrative” and please place the following justification in paragraph
form.”

ASAM Dimension 6: Recovery Environment

● Rating is 2
● The following information is required:
○ Support ex. Family
○ Income
○ Food stamps
○ Medical insurance
○ Last worked
○ Engaged in 12 steps program while in treatment or outside of treatment
○ Probation on or off
○ Current charges
○ Homeless

Things to consider for Dimension 6:

Helpful questions from the assessment:

● Are you facing any challenges right now?
● What is your current living condition?
● When's the last time you've been employed?
● Do you have a support system?
● Do you go to 12 step programs?
 ● Do you have a history of incarceration?
● Who's the person you’d turn to for any emergency? - can use emergency contact from
intake assessment

You may use the following prompt on ChatGPT:

“Please put the following information in paragraph form for Mr.Client’s recovery environment:
*insert the question & answer for ChatGPT to use*”

Example Clinical Narrative:

Creating the Justification for PHP: Essential to use ChatGPT for this part.
Type in the prompt :
“Please write Mr. McNair a justification for a substance abuse partial hospitalization program for
the following “prompt:client’s narrative” and please place the following justification in paragraph
form.”

Recommendation
Note:
● Recommendation of why they need treatment to have services.
● We do not use a code for recommendation
● All the treatment and intervention, barriers to address and discharge criteria per
dimension will be under Recommendation.
1. Click on the following option (to which level of care they belong):
 2. Click on “Recommendations” under PHP Update

Type in “Recommendation for Partial Hospitalization Program” (or whichever program they are
in for)
Ask the following questions. Take note of the answers and let ChatGPT make the whole thing
into a paragraph form.

Treatment and Intervention (format)

Treatment and Intervention:

Dimension 1
“Monitor and manage withdrawal symptoms through medical supervision.
Utilize medication-assisted treatment to manage cravings and stabilize the client during
detoxification.
Educating the patient on the importance of an ongoing support system to prevent relapse.”

Barriers to Address:

Discharge Criteria:

Treatment and Intervention:

Dimension 2
“Referral to a health care provider for regular medical check ups and coordination.”

Barriers to Address:

Discharge Criteria:

Treatment and Intervention:

Dimension 3
“Mental health support offering resources for mental health support including psychiatric
evaluation and treatment.”

Barriers to Address:

Discharge Criteria:

Treatment and Intervention:

Dimension 4
“Motivational interviewing to enhance motivation and readiness for change educating clients on
the awareness of the negative impacts of substance use and benefits of sobriety.”

Barriers to Address:

Discharge Criteria:

Treatment and Intervention:

Dimension 5
“Educate clients about relapse prevention planning, regular monitoring through urine tests and
other compliance measures.”

Barriers to Address:

Discharge Criteria:

Treatment and Intervention:

Dimension 6
“Offering resources for housing and employment, building a supportive social network.”

Barriers to Address:

Discharge Criteria:

Example:

Treatment Plan
Notes:
● Treatment plans are due on a monthly basis regardless of what level of services the
patient is in.
If you are on the patient's Chart Face, navigate to the Treatment Plan by selecting 'Treatment
Plan' from the filter options, then click on 'Work Areas'.

After doing so, you will be directed to the page below.

Another way to go to the Treatment Plan work area is to click on the “Treatment Plan” option.
See below.
Which will redirect you to this page.

If you need to add a new treatment plan, click on the green +. See below.
Making a new treatment plan:

1. Click on the . The following tab, boxed in red, will show up. Fill it out accordingly.
Don’t forget to click save.
● Last Date - the day of last initial treatment was done or the day you are doing the new
treatment plan.
● Due date is the date after a month.
● Always click “Wonder Works LLC”
After clicking save, click “Open” on the most left side of the screen. Then, you will be directed to
the page below. Afterwards, click on “Add a New Problem/Need”
2. Click on “Need-Manif Detail” tab
3. Click on “Substance Use Disorder”. Next, select the drug of choice which you can find
from the assessment.
4. Select the appropriate details.
 5. Afterwards, go to “Long Term Goal”

You will then be directed to this page:

6. Click on “Will Maintain Total Abstinence”

7. Pick a target date

8. Go to “Short Team Goal(s)

9. Click on “Opiate Use” and select a short term goal.

10. Then, select frequency and other details.

- For the target date, since 1 treatment plan is due every month, the target month should
be 1 month in advance from the date you are presently working on the treatment plan.
- For frequency, daily is selected as the patient will practice the short term goal on a daily
basis.
- For progress, select “plans to start soon”
11. Go back to step 9 and repeat the process until step 10 since we need at least 2 short
term goals for every treatment plan.
12. Go to Intervention(s)

13. You need to select an intervention per selected short term goal.
Next, select the frequency and other details accordingly.

See below when the two short term goals has assigned interventions.
14. Go to “Strengths”
15. Remove the data on the yellow field and select the “Strengths” template on the right side
of the screen.
The information here will come from the intake assessment. Leave only the information we have
from the assessment and delete the rest.

16. Next, click on “Barriers”

17. Remove the data on the yellow field and select the “Barriers” template on the right side
of the screen.
The information here will come from the intake assessment. Leave only the information we have
from the assessment and delete the rest.
18. Next, go to “Status”
19. Click “Face to Face”
After clicking on “Face to Face”, click “remarks on the bottom left side of the screen and the
following will show. Remember to edit the details under “TRANSITION PLAN” accordingly.
- Discharge date: set to a month ahead.

20. Click on “SNAP”

After clicking on “SNAP”, you will be directed to this page
21. Click on “Strengths” and select the following that corresponds to our patient’s answers
from the assessment.
22. Click on “Needs” and select the following that corresponds to our patient’s answers from
the assessment.

23. Click on “Abilities” and select the following that corresponds to our patient’s answers
from the assessment. (What the patient thinks he/she can do)
 24. Click on “Preferences for Treatment” and select the following that corresponds to our
patient’s answers from the assessment.
Note:
● Only select Group therapy, Individual therapy, “NA, AA, or Alanon”
● Do not select anything from the crossed out options.
 25. Click on “Back”

And you will be back to this page

 26. Select the option below

Then, this page will appear. Fill out the following.

Expected length of Stay: Always select “Approx. 3 months”

27. Then click on “See Shrub Post Discharge Services”

You will then be directed to the page below. Click on “Transition Plan”. Do not change anything
from the transition plans.
Then click on “Back”
28. Go to “Compile Plan” tab.
You will then be directed to the page below. Stop from there since Ms. Angela will be the one to
compile the plan.
29. If the patient has more than 1 drug of choice, you have to go back to the “List of Active
Needs” tab and start the process all over for each drug of choice.
Treatment Plan Backlogs
● When working on treatment plan backlogs, you need to be creative in using the current
information we have on that patient that has missing treatment plans.
1. Go to the Chart Room and look up the patient you are going to work on. Then click the
name.
2. You will then be directed to the client’s Chart Face
3. Scroll down to the patient’s available progress note and click on “Compile Note”
4. You will be directed to this page. Next, click on “Print” to download the PDF.
 5. Go to this website to convert the PDF file to an editable Word document.
https://www.ilovepdf.com/pdf_to_word
That file will then be your workspace to do the treatment plan backlog as it will act as a template
for you to fill in the progress note summary and DAP.
6. We have to change the dates on that file. You also need to copy the electronic signature
from a previous file and paste it into the new progress note you are working on.
7. After working on the file, upload it on the upload ICANotes website for them to be
compiled in the system.
Group Notes
● Process within 24-48 hours.
● IOP - Group notes are done 4 days a week. 2.5 hours a day. (9am - 12pm
(approximate))
● PHP - Group notes are done 7 days a week. 6 hours a day with 1 hour lunch (9am to
4pm)

Go on to the Chart Room and click on “Therapy Groups”

After clicking, you will be directed to the page below.

1. You can either SELECT a group (different level of care) or CREATE a new one.
If you select a group, data from “Previous Sessions” and “Members (PHP Groups) will show.
Note: “Members (PHP Groups) is the roster of clients under PHP Groups

❗Once a new intake assessment has been processed, we need that patient to be
added in the system immediately.❗
 2. If you click on a previous session, the following tabs will appear.

❗Never mark people as absent because they cannot be billed.❗If you see someone
marked as absent, please untick the box because they need to be billed.
3. To add a new group note. Click the + sign beside “Previous Session”. The “Therapy
Group Session Entry” tab will then appear.
Fill out the following:
● Date - make sure the date you are trying to make a group note for matches.
● Note Title (if no particular title, just put “Group Therapy Note”)
● Clinician - change to Ms. Angela
● Don’t change the code since this is the code for PHP

● Click Save.

4. After clicking save, the following tabs will appear. Click on the yellow space to create a
note.
5. This tab will appear for you to write the notes. Always select the “Corrected PHP with
right times please use” template option.
This is the template. Type in Ms. Angela’s name as the screenshot below.
 6. Go to ChatGPT to create the “Group Topic and Summary”
❗You need to have the handbook open❗Client Handbook - Matrix Intensive Outpatient
Treatment for People with Stimulant Use Disorders.pdf

A sample prompt to use on ChatGPT to create a group therapy note:

“Create a 3 detailed paragraphs about substance abuse group therapy note about the topic of
how to cope with triggering thought of drug and craving use (topic) using of some of the
following info: “insert the copied info from the handbook”

Example:
Literally copy the information given by ChatGPT and paste it on the yellow space under Group
Topic and Summary. Make sure to remove any unnecessary symbols, etc.

7. Remove “Leader Interventions”

8. For the “Plan”
Go to ChatGPT and type the following prompt: “Suggest a plan for the next group session topic
in 3 sentences”
9. Click “Back”

10. Since we have a Group Therapy Note done, We now proceed to create the “Individual
Notes” for everyone in the roster. We create individual notes by clicking on the
“+Remarks” button.
11. After clicking “+Remarks” the popup below will appear. Click on the “Individual Remarks
Template”
Individual Remarks Template
 12. For the “Pt. stated:” go on ChatGPT to generate a direct quotation in reference to the
group topic. Ask ChatGPT to generate enough quotations for all of the clients included in
the roster.

You may use the prompt: “Please write 30 individual direct quotation client remarks in reference
to the group topic above”
Pick one out and paste it on the individual note for Pt. stated.
13. Next, Appearance: Could be the same per person but select accordingly per person.
Better to alter a bit.

14. Next, Behavior. Same procedure as above.

15. Stage of Change: 9/10 “Contemplation” - as most patients are contemplating about using
again.

16. When the client remarks, the icon will turn into green.
 17. Repeat process for individual notes for all of the clients included in the roster.

Individual Progress Notes

Go to a patient’s Chart Face. Click on “Therapist”
After clicking, you will be directed to this page.
1. Click on “1 on 1 Progress Template note PHP and IOP
This template will then show up. You have to answer the questions with patient’s information.
When filling up the template questions, please use this file: WW_Progress Note_Template.
 2. After getting the answers, open up ChatGPT and type in the prompt:
I need the following Answers to the Questions below in paragraph format. Please make the
paragraph flow smoothly and make it very detailed.
*insert the filled out template*

Let ChatGPT do its magic. This will then be your progress note summary

3. Next, ask ChatGPT the below:

“Please make the previous into DAP format” - This will then be your breakdown for your DAP
note format (Data, Assessment, Plan)

The file below is the example of a progress note:

Progress Note Example File: Progress note.pdf

4. Copy the DAP information from ChatGPT and past it on the Interval History space
2. Click on “PN, part 2”. You will then see the page below.
Make sure you change the Clinician name accordingly. (This is the only thing you have to do on
PN, part 2)
For PHP, select Ms. Angela.

❗Important Notes❗

Progress note - twice a month

Treatment Plan - 1 due every month
1 on 1 notes - twice a month

PHP - 1on1 notes - 1 every single week

Duration of the 1 on 1- 20 mins for each session
-make sure that you add 5 mins if you start the next one.

PHP- 8 30 to 4 30

- Never indicate something on a note that says our housing address as we are strictly
clinical.

PROCEDURE (new intake)

● When we get a new intake patient, they talk to a doctor (NP OnCall - Nurse Practitioner
on call).
 ● An assessment will be done by the NP OnCall. The assessment will then be emailed to
Ms. Malika / VA /Documenter.

Uploading Documents
● The Documenter will then upload the Bio-Psych assessment from the NP OnCall to
ICANotes.
1. Go to the patient’s chart face and click the “Documents” tab.
 2. Go to upload.icanotes.com. Log in your ICANotes credentials.
This is what you see when inside the upload website.
3. Search the patient’s name. The website requires the patient to be “active” in ICANotes in
order to be searched on this upload website. If the client happens to be inactive, turn
them to “active” on ICANotes. After uploading files for an inactive patient, don’t forget to
turn their status back to inactive. See below.
4. Once you locate the patient, this will appear on the upload website.
5. Fill out the following then upload.
Urinalysis Acutis
Go to https://acutis.careevolve.com/.
Username: MShabazz8351
Password: Acutis!!8351
Location: 14845

Once logged in, you will see this.

1. Look up the patient’s name and export their file into a pdf format.
File name:
2. Locate the patient on the upload ICANotes website
3. Fill out the following then upload.
Urinalysis Trinity Labs
Go to https://trinity.safemedicaldata.com/login.aspx?refresh=1
Username: WonderWorks
Password: Wonder2023!!

1. Log in the account on this page.

Court Letter
Sometimes, people of authority require proof or documentation of the client’s progress.
Court letter template: WWH_ Court Verification Email Template