Treatment Plan (ASAM-Aligned)

Patient Name: [Patient full name]    DOB: [MM/DD/YYYY]    MRN: [Medical record number]    Plan Date: [MM/DD/YYYY]    Plan Type: [Initial / Review / Update / Transfer / Discharge-focused]    Target Review Date: [MM/DD/YYYY]    Author: [Name, credentials]    Setting/Program: [Program name, level of care, modality]

Clinical Basis

[Clinical rationale for this plan] (4–6 sentences summarizing relevant SUD and co-occurring diagnoses with specifiers; presenting problems and risks justifying current level of care; key baseline indicators such as days used in last 30, last use date, validated symptom scores, and functional domains impacted. For updates, reference last comprehensive assessment date and note only what has changed.)

Patient Recovery Vision and Strengths

Patient Priorities/Values: [Patient-stated recovery vision and priorities] (Include at least one direct quote when available. If the patient is unable or unwilling to articulate goals, document the reason and plan to revisit.)

• Strengths and Protective Factors: [Supports, prior recovery successes, motivation sources, employment/education, cultural/spiritual resources, coping skills]
• Treatment Preferences and Constraints: [Scheduling, transportation, modality preferences, accessibility needs]

Multidimensional Assessment Summary

(For each relevant dimension, note risk level, key drivers/evidence, and link to problem list. Keep each to 1–3 lines.)

• Dimension 1 (Acute Intoxication/Withdrawal Potential): [Risk level] — [Key drivers] — [Problem list linkage]
• Dimension 2 (Biomedical Conditions): [Risk level] — [Key drivers] — [Problem list linkage]
• Dimension 3 (Emotional/Behavioral/Cognitive Conditions): [Risk level] — [Key drivers] — [Problem list linkage]
• Dimension 4 (Readiness to Change): [Risk level] — [Key drivers] — [Problem list linkage]
• Dimension 5 (Relapse/Continued Use Potential): [Risk level] — [Key drivers] — [Problem list linkage]
• Dimension 6 (Recovery/Living Environment): [Risk level] — [Key drivers] — [Problem list linkage]

Barriers Preventing Safe Step-Down: [List top barriers with brief rationale for each]

Safety and Crisis Planning

(Include full section only when acute or foreseeable risk is present. If no acute safety risks identified, state: "No acute safety risks identified; routine monitoring continues.")

Current Risk Level and Drivers: [Risk type(s), level, and key evidence]

• Protective Factors: [Supports, reasons for living, coping skills]
• Safety Plan: [Status: created / updated / reviewed] — [Location/access]
• Crisis Resources Provided: [Hotlines, mobile crisis, emergency instructions]
• Overdose Prevention: [Naloxone access: yes / no / provided] — [Education provided] — [Additional harm reduction measures]

Problem List

(List problems in priority order by clinical severity. Each problem links to goals, objectives, and interventions below.)

1. Problem 1: [Behavioral/functional problem statement] — Diagnosis: [Related diagnosis] — ASAM Dimension: [Dimension linkage] — Baseline: [Severity metric] — Impact: [Functional areas affected] — Responsible Discipline: [Primary discipline]
2. Problem 2: [Behavioral/functional problem statement] — Diagnosis: [Related diagnosis] — ASAM Dimension: [Dimension linkage] — Baseline: [Severity metric] — Impact: [Functional areas affected] — Responsible Discipline: [Primary discipline]
3. Problem 3: [Behavioral/functional problem statement] — Diagnosis: [Related diagnosis] — ASAM Dimension: [Dimension linkage] — Baseline: [Severity metric] — Impact: [Functional areas affected] — Responsible Discipline: [Primary discipline]

Goals, Objectives, and Interventions

(For each problem, document long-term goal, measurable short-term objectives, and interventions with responsible party and frequency.)

Problem 1: [Problem label]

Long-Term Goal: [Patient-centered outcome aligned with recovery vision]

1. Objective 1.1: [Measurable target, timeframe, metric, measurement source]

   • Clinician Intervention: [Intervention and evidence-based approach] — [Responsible party] — [Modality] — [Frequency/duration] — Status: [Planned / Ordered / Active]
   • Patient Action Step: [Patient action] — [Frequency] — [Support/tools needed] — Status: [Planned / Active]

2. Objective 1.2: [Measurable target, timeframe, metric, measurement source]

   • Clinician Intervention: [Intervention] — [Responsible party] — [Modality] — [Frequency/duration] — Status: [Planned / Ordered / Active]
   • Patient Action Step: [Patient action] — [Frequency] — [Support/tools] — Status: [Planned / Active]

Problem 2: [Problem label]

Long-Term Goal: [Patient-centered outcome]

1. Objective 2.1: [Measurable target, timeframe, metric, measurement source]

   • Clinician Intervention: [Intervention] — [Responsible party] — [Modality] — [Frequency/duration] — Status: [Planned / Ordered / Active]
   • Patient Action Step: [Patient action] — [Frequency] — [Support/tools] — Status: [Planned / Active]

2. Objective 2.2: [Measurable target, timeframe, metric, measurement source]

   • Clinician Intervention: [Intervention] — [Responsible party] — [Modality] — [Frequency/duration] — Status: [Planned / Ordered / Active]
   • Patient Action Step: [Patient action] — [Frequency] — [Support/tools] — Status: [Planned / Active]

Problem 3: [Problem label]

Long-Term Goal: [Patient-centered outcome]

1. Objective 3.1: [Measurable target, timeframe, metric, measurement source]

   • Clinician Intervention: [Intervention] — [Responsible party] — [Modality] — [Frequency/duration] — Status: [Planned / Ordered / Active]
   • Patient Action Step: [Patient action] — [Frequency] — [Support/tools] — Status: [Planned / Active]

2. Objective 3.2: [Measurable target, timeframe, metric, measurement source]

   • Clinician Intervention: [Intervention] — [Responsible party] — [Modality] — [Frequency/duration] — Status: [Planned / Ordered / Active]
   • Patient Action Step: [Patient action] — [Frequency] — [Support/tools] — Status: [Planned / Active]

Service Summary

(Consolidated list of services. Omit if service details are clear within each problem section.)

• [Service type] — [Frequency] — [Start date] — [Anticipated duration/review] — [Location/modality]
• [Service type] — [Frequency] — [Start date] — [Anticipated duration/review] — [Location/modality]

Care Coordination

• Coordination Need: [Entity/provider type] — Reason: [Clinical or social rationale] — Status: [Planned / Placed / Accepted / Scheduled / Completed] — Follow-up Owner: [Name/discipline] — ROI/Consent: [On file / Pending / Unknown—verify before contact]
• Coordination Need: [Entity/provider type] — Reason: [Rationale] — Status: [Status] — Follow-up Owner: [Owner] — ROI/Consent: [Status]

Transition Criteria

Step-Down Readiness: [Measurable indicators supporting transition to lower intensity, including specific thresholds, durations, and evidence sources]

Step-Up Triggers: [Indicators requiring more intensive services: escalating withdrawal/medical risk, worsening suicidality, recurrent overdose, loss of safe housing, inability to participate at current level]

Target Trajectory: [Anticipated next level of care if progress occurs] — [Supports needed at that step]

Patient Involvement

[Patient participation in planning, options discussed, what patient chose and declined with reasons, education provided, and assessment of understanding] (If patient declined to participate, document reason and plan to revisit.)

Review Schedule

Next Review: [Date or interval] — Earlier Review Triggers: [Clinical change / relapse / missed visits / safety concerns]

(For plan updates: [What changed since last plan and rationale])

Signatures

Clinician Signature/Credentials/Date: [Signature block]    Patient Signature/Date: [Signature, or "Refused to sign" with reason documented]