Periodic Reassessment/Continued Stay Review (ASAM Criteria)

Note Type: Periodic Reassessment / Continued Stay Review (ASAM Criteria)

Date/Time of Note: [date/time of note]

Date/Time of Patient Contact: [date/time of patient contact]

Author: [author name, credentials]

Patient: [patient name or identifier]

Current ASAM Level of Care: [current level of care]

Setting/Program: [program name and setting]

Review Interval: Covering [start date] to [end date]

Reason for Reassessment: [scheduled periodic review / payer concurrent review / status change / other trigger]

Executive Summary

[High-signal synopsis for utilization review] (Provide 3–6 concise sentences including: primary substance use disorder and key co-occurring conditions; overall trajectory since last review [improving / stable / worsening] with 1–2 key events; highest current risks; recommended level of care [continue current LOC / step-down / step-up / transfer] with primary dimensional drivers; one-sentence forward plan with timeline.)

Interval History and Objective Findings

(Summarize the interval since last review. When information is unavailable, document as "not assessed/unknown" with reason and plan to obtain.)

• Substance use since last review: [use pattern, last use dates by substance, cravings, overdose or adverse events]
• Withdrawal/intoxication course: [presence/severity, complications, response to management]
• Treatment participation and response: [attendance, engagement, skills acquisition, care plan adherence]
• Medical and psychiatric events: [ED visits, hospitalizations, notable symptoms, medication changes]
• Functional status and recovery environment: [housing, employment, supports, legal issues, access barriers]
• Objective data: [relevant vitals, withdrawal scale scores with dates, toxicology results with dates, MOUD adherence, standardized measures with trends] (Include only data available for this interval.)

Safety Assessment

(Explicitly reassess current risk state; do not copy forward from prior notes. Use direct patient quotes when statements materially affect risk or placement decisions.)

• Suicide/Self-Harm Risk: [ideation status, plan/intent/means assessment, recent behaviors, risk and protective factors, safety planning status]. Overall risk level: [low / moderate / high / imminent] with brief rationale.
• Overdose Risk: [current use risk, tolerance changes from recent abstinence, polysubstance exposure, fentanyl risk, naloxone access and education status].
• Withdrawal Risk: [likelihood and anticipated severity, seizure/DT risk factors if applicable, monitoring needs].
• Safety in Lower LOC: [can / cannot] maintain safety and recovery in a less intensive setting because [brief rationale].
• Current Safeguards: [observation level, safety plan status, crisis contacts, escalation thresholds].

ASAM Multidimensional Reassessment

(Address all six dimensions. For each, document: current severity/risk rating, change since last review [improved / stable / worsened] with factual anchors, and current needs. If stable, state "reviewed, no material change since [date].")

• D1 - Intoxication/Withdrawal/Addiction Medications: [severity rating, current withdrawal/intoxication status, medications including MOUD with doses, adherence, monitoring needs, change since last review].
• D2 - Biomedical Conditions: [severity rating, active medical issues affecting placement or safety, treatments, change since last review].
• D3 - Psychiatric/Cognitive Conditions: [severity rating, active symptoms, stability, insight, treatment response, change since last review].
• D4 - Substance Use-Related Risks: [severity rating, relapse likelihood, triggers, cravings, impulsivity, high-risk behaviors, change since last review].
• D5 - Recovery Environment: [severity rating, housing safety, social supports and risks, access barriers, legal factors, change since last review].
• D6 - Person-Centered Considerations: [severity rating, patient preferences and goals, engagement level, motivational factors, barriers, change since last review].

Dimensional Drivers for LOC Decision: [1–3 dimensions most responsible for current LOC recommendation with brief rationale for each]

Plan and Medical Necessity

• Progress Toward Goals: [measurable indicators: abstinence days, toxicology trends, symptom measures, attendance, skill use]. [barriers identified and plan adjustments].
• Continued Stay Justification: [services current LOC provides not feasible at lower intensity]. [why continued stay is medically necessary now, with specific risks if stepped down]. [why higher LOC is not required]. [active treatments being delivered].
• Transition Planning: [target next LOC]. [specific measurable criteria for step-down or discharge]. [barriers and mitigation steps]. [linkages arranged with dates: appointments scheduled vs. referrals pending]. [patient stated preference].
• Estimated Timeline: [anticipated duration at current LOC, next review date].

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Clinician Signature/Credentials: [name, credentials]

Date/Time Signed: [date/time]

Supervising Clinician Co-Signature: [name, credentials, date/time] (Include only if required by program policy.)