Substance Abuse Sample Notes

Sample substance abuse notes created in ICANotes with no typing required.

The increasing complexity of the healthcare industry has made it more difficult for behavioral health clinicians to create documentation that satisfies regulatory standards. However, with ICANotes, you can compile detailed substance abuse therapy notes in inpatient and outpatient settings that are both comprehensive and convenient. We expedite the process for you, making it easy to take the most thorough notes for every patient or group.

When you use our advanced electronic health record (EHR) software, you can take advantage of the most clinically intuitive charting solution on the market.

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Inpatient Substance Abuse Therapy Notes

Initial Assessments

With our behavioral health EHR software, you'll begin by conducting a series of initial assessments, documenting all your patient's key medical, social and behavioral information. These evaluations include the bio-psychosocial, initial psychiatric and chemical dependency initial nursing assessments.

These notes will detail the individual's:

  • Illness.
  • Pattern of use.
  • Symptoms.
  • Medical and psychiatric history.
  • Unique needs.
  • Relapse risk rating.
  • Legal history.
  • Behavior.
  • Diagnoses.


All diagnoses are organized per International Classification of Diseases (ICD)-10 and compiled into a drop-down menu. The initial assessments include fields for patient recommendations and medication orders and also have evaluation and management (E/M) codes.

Treatment Plans

After the initial evaluations, our software will help you construct an individualized treatment plan. This section will outline the patient's diagnosis and current medications before providing a series of short- and long-term goals. The software also provides a field where you can enter intervention solutions to the patient's substance abuse and mental health disorders. The initial treatment plan also includes a transition plan and addresses potential strengths and barriers.


Progress Notes

Additionally, the EHR software will help you keep track of the patient's substance abuse progress notes, which are designed to capture the individual's history and exams while providing diagnoses and clinical recommendations. The different progress notes you can write include:

  • Nursing progress notes. These notes detail the patient's behavior, symptoms, hygiene, withdrawal assessment, mental status exam and a series of treatment plans.
  • Individual psychotherapy notes. Psychotherapy notes include the patient's mental health and behavioral problems, therapy content and intervention and treatment instructions.
  • Group therapy notes. Substance abuse group notes detail the group type, patients present, group leader interventions, appearance and behavior, mental status exam, stage of change, treatment plans and any additional notes.

Discharge Summaries

After your sessions, our software will provide you with resources to create an inpatient discharge summary. This printout includes the clinician's narrative, discharge status and instructions. It also features a mental status exam that offers a final patient evaluation, diagnosis, medications and test results.

Outpatient Substance Abuse Progress Notes

Initial Assessments

Like inpatient evaluations, all outpatient substance abuse therapy notes will begin with numerous assessments, starting with the chemical dependency assessment. This examination outlines six patient risk ratings, such as mental health and treatment acceptance relapse.

During the initial psychiatric assessment, you'll detail all the patient's most crucial medical, social, family, and psychiatric history and provides information from a mental exam and treatment recommendations.

Progress Notes

The outpatient substance abuse progress notes are increasingly extensive and easier to document than ever with our EHR software. Our program will help you outline dozens of essential patient details, such as behavior, mental exams, symptoms, diagnoses, and intervention and treatment plans. These notes include:

  • Outpatient therapy progress note.
  • Couples therapy progress note.
  • Nursing progress note.
  • Outpatient progress note.
  • Psychotherapy progress note.

After the patient progress notes, you can use our software to create a bio-psychosocial assessment and a progress note by the American Society of Addiction Medicine (ASAM) Dimension.

Use Our Advanced EHR Software Today

You can solidify and perfect your behavioral health documentation process with ICANotes. Our charting solutions are fast and efficient to help improve your note-taking processes.

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