Discharge Summary/ Continued Care Plan
Discharge/Transfer Criteria
Date of Discharge/Transfer __________ Patient Name _____________________________________
Chemical Dependency Professional (CDP) summary report of patient progress towards meeting short and long range treatment goals for each Dimension listed on the Individual Treatment Plan, based on the Chemical Dependency Assessment:
DIMENSION _____ Present ASAM PPC Level of Care _________
As evidenced by:_____________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________
The patient has achieved the treatment goals in the individual treatment plan and has resolved the problem that justified admission to the present level of care.
The patient has been unable to resolve the problem that justified admission to the present level of care, despite amendments to the treatment plan.
The patient has demonstrated a lack of capacity to resolve the problem at the present level of care.
The patient has experienced an intensification of the problem that cannot be treated effectively at the present level of care.
The patient has developed a new problem in this Dimension that cannot be treated effectively at the present level of care.
DIMENSION _____ Present ASAM PPC Level of Care _________
As evidenced by:_____________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
The patient has achieved the treatment goals in the individual treatment plan and has resolved the problem that justified admission to the present level of care.
The patient has been unable to resolve the problem that justified admission to the present level of care, despite amendments to the treatment plan.
The patient has demonstrated a lack of capacity to resolve the problem at the present level of care.
The patient has experienced an intensification of the problem that cannot be treated effectively at the present level of care.
The patient has developed a new problem in this Dimension that cannot be treated effectively at the present level of care.
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The patient presently meets the ASAM PPC admission criteria for treatment in Level _____.
Treatment will continue at: __________________________________ Start Date _______________
The patient has elected not to continue with the recommended treatment.
The recommended treatment is not available to the patient because___________________.
No further treatment is needed or recommended at this time.
CDP Signature ______________________________________________ Date ____________
Patient Signature ____________________________________________ Date ____________
Page # __________
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