Opioid Abuse Treatment-Outpatient Client Record Review

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Outpatient Client Record Review
Name
Course
Institution
Date
Opioid abuse treatment-Outpatient Client Record Review
Admission and Intake Data

 Information

 

 

Date and Type of Admission

 The date and time of admission are recorded and client has a history of anxiety
The type of admission is for opioid drug addiction (substance use disorder)

ID/Demographic Info

 First, middle and last name are included
The client was born 1st May 1970 and is a 15 year old male
He is a mechanic and is married with three children
He is a history of alcohol use, but has been diagnosed with substance abuse because of opioid addiction
He is currently addicted to opioids after having been diagnosed with opioid medication following a vehicle accident
However, he no longer feels pain from the accident

Social/Econ/Family History

 Record the Socioeconomic Status as reported from low, middle and high SES
Record family background and history
Record the family conditions

Education

 Associate degree with certifications and training over years

Employment History

Experience in various industries, but currently self employed

Criminal History/Legal Status

 There is no criminal history and has mostly been fined for traffic infractions

Physical and Mental Health History

 Onset of mental health history problems
Aggravating factors – alcohol use, family problems
Treatments previously tried
Mental status examination (MSE) shows he is affected by anxiety and substance abuse disorder
Include history of alcohol and drug use

AOD History

 Record of Alcohol and other drug (AOD) abuse
Given ongoing sym...