Client, Encounter, and Required Battery
Set the population and decision context. The protocol matrix will identify the expected core and conditional measures.
Population and Trigger Flags
| Assessment | Status | Who / When | Latest Result | Cadence |
|---|
Clinical Flags and Required Responses
Flags are generated by scored instruments and urgent needs. They do not make a disposition decision.
Comprehensive Reassessment and Mental Status Examination
Use this as a concise outcomes-book summary. Complete the full organizational biopsychosocial assessment when required.
Mental Status Examination
ASAM Multidimensional Assessment Result and Evidence Shell
Records dimensional ratings and rationale without reproducing proprietary ASAM placement algorithms. Use the current authorized ASAM Criteria and trained clinical judgment.
| Dimension | 0–4 Evidence Rating | Current Evidence | Treatment / Monitoring Implication |
|---|
Columbia Suicide Severity Rating Scale — Outpatient Screener + Clinical Response
Use the approved organizational version and follow exact training. This embedded screen supports the recent outpatient pathway and requires clinical risk formulation.
Patient Health Questionnaire — 9 (PHQ-9)
Over the last two weeks, how often has the client been bothered by each problem?
Generalized Anxiety Disorder — 7 (GAD-7)
Over the last two weeks, how often has the client been bothered by each problem?
Brief Addiction Monitor — IOP, Past 7 Days
Produces separate Use, Risk, and Protective scores. There is no single validated total or universal cutoff; interpret change over time and item-level clinical meaning.
Item 7 — Substance-specific days used (not included in BAM Use composite)
WHODAS 2.0 — 12-Item Authorized Score Entry
Enter the twelve item scores from the authorized WHO/CMS form. This book calculates the simple raw sum; it does not reproduce the protected questionnaire text or WHO IRT algorithm.
CBEI Functional Capacity Survey
Cornerstone’s internal planning measure for Confidence, Boundaries, and Emotional Intelligence. It is not a validated diagnostic, risk, or level-of-care instrument.
Maslow and Eight Dimensions of Wellness Needs Assessment
Rate barrier severity: 0 none/stable, 1 mild, 2 moderate, 3 severe/blocks progress, 4 urgent or immediate safety/access issue. Assign action, owner, due date, and verification.
Maslow Priority Tiers
| Tier | Need / Barrier | Severity 0–4 | Action / Referral | Owner | Due |
|---|
Eight Dimensions of Wellness
| Dimension | Need / Barrier | Severity 0–4 | Action / Referral | Owner | Due |
|---|
Phase Readiness Review
Rate observable evidence: 0 not established/unsafe, 1 rarely, 2 partial/inconsistent, 3 usually demonstrated, 4 consistent and independently demonstrated.
Transition Barriers and Outpatient Readiness Assessment
Rate each domain: 0 unstable/not established, 1 partial/in progress, 2 ready/active. Any hard stop overrides the numerical band.
| Readiness Domain | 0–2 | Barrier / Evidence | Action | Owner | Due | Verification |
|---|
Closed-Loop Handoff Milestones
PTSD Checklist for DSM-5 — PCL-5
Keeping the worst event in mind, rate how much each problem bothered the client in the past month: 0 not at all to 4 extremely.
AUDIT-C
Three-item alcohol-use screen. The positive threshold is configurable because programs and payers may use different cut points.
Drug Abuse Screening Test — 10 (DAST-10)
Past 12 months. “Drug” excludes alcohol and tobacco and includes nonmedical use of prescribed or over-the-counter medications.
BARC-10 Authorized Score Entry
Enter ratings from the authorized Brief Assessment of Recovery Capital instrument. Short cues below are navigation aids and do not replace official item wording.
LOCUS and TAPS Result-Entry Forms
Record outputs from the authorized instrument or licensed platform. This book does not reproduce protected items or decision rules.
LOCUS — Authorized Result Entry
TAPS — Authorized Result Entry
Conditional Specialty Screen Matrix
Each positive screen must create a response: referral/action, owner, due date, verification, and treatment-plan linkage.
| Domain | Screen / Finding | Status | Action / Referral | Owner | Due |
|---|
Outcome History and Trend
Add scored results from each assessment. Export the client record to JSON after each review and move it to an approved storage location.
| Date | Context | Measure | Score | Interpretation | Baseline Δ | Notes | Action |
|---|
Prior-Authorization / Continued-Stay Medical-Necessity Summary
Build the six-sentence decision record: why this level, why now, why not lower, why not higher, why this frequency, and what proves continued need or readiness.
Assessment-to-Treatment-Plan Crosswalk
Each active service lane should show the assessed need, measurable client objective, distinct provider intervention, frequency, target, and outcome evidence.
| Service / Objective Lane | Assessed Need / Score | Measurable Client Objective | Provider Intervention | Responsible Discipline | Frequency | Target / Evidence |
|---|
Administration, Scoring, Source, and Licensing Notes
Confirm current payer rules, instrument versions, licenses, and organizational policies before controlled deployment.
Embedded: PHQ-9, GAD-7, C-SSRS outpatient screener, PCL-5, BAM-IOP, AUDIT-C, DAST-10 under stated terms, and Cornerstone internal tools. Authorized score entry: WHODAS, BARC-10, LOCUS, and TAPS where permissions or exact authorized administration matter. Protected clinical framework: ASAM evidence shell only; no placement algorithm.
- PHQ-9 / GAD-7: Patient Health Questionnaire and Generalized Anxiety Disorder tools; use current official English forms and scoring. The instrument publisher states the PHQ and GAD tools may be used without copyright restriction.
- PCL-5: Weathers et al., National Center for PTSD. Public-domain instrument intended for qualified health professionals and researchers. Total score 0–80; local provisional threshold must be selected for the population and purpose.
- BAM-IOP: U.S. Department of Veterans Affairs, past-seven-day version. Use = items 4–6; Risk = 1,2,3,8,11,15; Protective = 9,10,12,13,14,16. Item 14 is converted to 0/4 for the protective composite. No universal cutoff.
- C-SSRS: Columbia Lighthouse Project outpatient screener. Use exact organizational training, clinical judgment, and local emergency procedure. The automated prompt in this book mirrors the outpatient triage structure but does not replace risk formulation.
- WHODAS 2.0: World Health Organization / authorized implementation. This book contains score-entry fields and simple summation only, not the item text or IRT scoring algorithm.
- ASAM: American Society of Addiction Medicine. Proprietary criteria and decision rules are not reproduced. Use the current authorized edition and document the selected level and evidence.
- LOCUS: American Association for Community Psychiatry. Use an authorized version/platform. Enter only the completed result.
- DAST-10: Harvey A. Skinner / Centre for Addiction and Mental Health. Reproduction is limited by the instrument’s stated terms; preserve attribution and confirm organizational use.
- BARC-10: Brief Assessment of Recovery Capital. Use the authorized instrument wording; this book provides score-entry cues and total calculation.
- CBEI, Maslow/Wellness, Phase Readiness, and Transition Readiness: Cornerstone internal planning instruments. They are not validated diagnostic, suicide-risk, ASAM, LOCUS, or payer-authorization substitutes.