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The Importance of Keeping Thorough Patient Records

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A New England recovery center in Ellsworth, Maine was forced to shut down recently after operating on a conditional license since Dec. 31.

According to Maine news outlet Bangor Daily News, the Open Door Recovery Center failed to meet numerous regulatory standards required by the Maine Department of Health and Human Services. This includes failure to properly conduct background checks on employees and “incomplete treatment plans, patient records that did not document the treatment patients had received and some records that listed treatment for dates before the patients had even been admitted to Open Door programs.”

Like any clinical field, record keeping is paramount in treating addiction.

Tracking your journey in recovery will continue to benefit you, even after you have left your initial treatment.

Keep Thorough Substance Abuse Medical Records

According to Blueprint Recovery Center’s Executive Director, Jonathan Gerson, keeping thorough medical records in healthcare and substance abuse treatment is a crucial element of providing quality care.

“Substance abuse treatment requires a variety of professionals to support the medical, therapeutic, psychiatric and life goals of each patient,” Gerson said. “Accordingly, each professional must detail and communicate the patients observed strengths, weaknesses, successes and set-backs so that each element can work together synergistically.  A patient record in essence is a story of the individual, if the preceding chapter is clouded, the next chapter will follow suit.” 

The Importance of Extended Care

“Success rates in recovery are proven to be at a higher rate when a patient is provided extended care, with the consistency and stability of a singular treatment team,” Gerson said.  “With extended care being the model and aim of Blueprint Recovery Center, it is essential for the payor’s to have detailed patient records so that both the facility and payor can operate in tandem and provide the length of stay needed to properly treat the patient.”

Tracking your journey in recovery will continue to benefit you, even after you have left your initial treatment. Participating in extended care opportunities, including taking residence in community housing or attending group therapy at Blueprint gives clinicians the opportunity to assist you in changing problem patterns and behaviors.

For more on Blueprint Recovery Center’s extended care programs and community housing, let go and let’s chat.