NAADAC NCAC I cheat sheet

Biopsychosocial assessment covers substance use history, medical and psychiatric status, family and social functioning, legal issues, vocational status, and spiritual or cultural needs.

ASAM criteria use six dimensions: intoxication and withdrawal, biomedical conditions, cognitive and emotional issues, readiness to change, relapse potential, and recovery environment.

Screening is brief and identifies risk; assessment is comprehensive and supports diagnosis, severity, and level-of-care decisions.

DSM-5-TR substance use disorder uses 11 criteria within a 12-month period: 2-3 criteria mild, 4-5 moderate, and 6 or more severe.

CIWA-Ar scores alcohol withdrawal severity; COWS scores opioid withdrawal severity.

Mental status examination components include appearance, behavior, speech, mood and affect, thought process and content, cognition, insight, and judgment.

Suicide risk evaluation asks directly about ideation, plan, intent, means, prior attempts, and protective factors.

Screening tools include AUDIT for alcohol, DAST for drugs, PHQ-9 for depression, and GAD-7 for anxiety.

Goals are broad desired outcomes; objectives are measurable steps with timeframes that demonstrate progress toward the goal.

SMART objectives are specific, measurable, achievable, relevant, and time-bound.

A treatment plan links each assessed problem to a goal, measurable objectives, specific interventions, responsible staff, and target dates.

ASAM criteria guide selection of the least restrictive level of care that meets safety needs and treatment intensity.

Client participation in planning is documented; if the client declines to sign, the refusal is noted.

Many payers require treatment plan review at least every 90 days, with updates sooner when status or services change.

Discharge and transition planning begins at intake rather than at the end of treatment.

Each objective should be observable and measurable, not a restatement of the problem.

Referral is indicated when assessed needs exceed the program's scope, competence, licensure, or available services.

Referral matching considers level of care, language, culture, insurance, location, transportation, and provider availability.

A signed release of information is required before disclosing identifying information to most referral providers.

Warm handoff includes direct contact with the receiving provider and a confirmed appointment; cold referral provides information only.

Follow-up after referral verifies engagement, identifies barriers, and documents the outcome.

Emergency referral for imminent danger may proceed without consent, with the rationale documented.

Mandated reporting laws override confidentiality for suspected child abuse, elder abuse, or dependent adult abuse.

Referral documentation includes reason, provider, date, information shared, and outcome.

Case management functions include assessment, planning, linking, advocacy, monitoring, and evaluation.

Coordination spans medical, psychiatric, legal, housing, employment, transportation, and social services.

A shared care plan, used with client consent, reduces duplication and conflicting treatment recommendations.

Written agreements and role clarity reduce conflict among interdisciplinary team members.

The minimum necessary standard limits shared protected health information to what is needed for the coordination purpose.

Documentation of coordination includes date, participants, purpose, information exchanged, outcome, and next step.

Warm transitions require a confirmed receiving provider, appointment, medication continuity, and documented handoff.

Common barriers include transportation, childcare, cost, stigma, waitlists, and housing instability.

Motivational interviewing spirit consists of partnership, acceptance, compassion, and evocation (PACE).

OARS skills are open-ended questions, affirmations, reflective listening, and summaries.

The four MI processes are engagement, focusing, evoking, and planning.

CBT identifies cognitive distortions and maladaptive behaviors and tests alternative responses.

Contingency management provides tangible rewards for objective evidence of abstinence or attendance.

Relapse prevention identifies high-risk situations, coping skills, and warning signs; a lapse is a single slip, while relapse is a return to the previous pattern.

Trauma-informed care emphasizes safety, trustworthiness, peer support, collaboration, empowerment, and cultural humility.

Group rules typically address confidentiality limits, attendance, respect, and intoxication; confidentiality cannot be guaranteed in group settings.

Family psychoeducation improves understanding of substance use, communication, boundaries, and treatment engagement.

Education materials should match the client's health literacy, language, culture, and readiness to change.

Harm reduction education includes naloxone use, overdose response, safer use practices, and reducing stigma.

Family involvement requires the client's written consent unless a legal exception applies.

Prevention education targets risk and protective factors and includes life-skills development.

Person-first language, such as 'person with a substance use disorder,' reduces stigma.

Education about medications for opioid use disorder presents them as evidence-based treatment.

Mandated reporting and duty-to-warn laws may limit promises of absolute confidentiality to families.

SOAP note format uses subjective, objective, assessment, and plan sections.

DAP note format uses data, assessment, and plan sections.

BIRP note format uses behavior, intervention, response, and plan sections.

Documentation records objective, observable facts and client statements; speculation and opinions are avoided.

Progress notes link client status, interventions, response, and plan to treatment plan goals and medical necessity.

Errors are corrected with a single line, date, time, initials, and reason; erasures and backdating are prohibited.

Missed appointments, cancellations, and outreach attempts are documented.

Record retention follows state, payer, and federal requirements; 42 CFR Part 2 applies to federally assisted substance use disorder records.

NAADAC ethical principles include autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity.

Counselors practice within their scope of practice and refer when a client's needs exceed their competence.

Informed consent covers the nature of services, risks, benefits, alternatives, confidentiality limits, and fees.

Confidentiality exceptions include imminent danger to self or others, suspected abuse or neglect, and valid court orders.

NAADAC ethics prohibit dual relationships that impair objectivity or exploit clients.

Ethical dilemmas require supervision or consultation, with the decision process documented.

Impaired or unethical colleagues are reported to the appropriate supervisor, licensure board, or authority.

Certification renewal requires continuing education and compliance with the certifying body's requirements.