Fillable Individual SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS NOTES (County of Los Angeles / Internal Services Department)

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Individual SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS NOTES (County of Los Angeles / Internal Services Department)

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BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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SUBSTANCE ABUSE PREVENTION AND CONTROL
PROGRESS NOTES (GIRP FORMAT)
Revised 9/5/17 1
PROGRESS NOTE TYPE
1.
Date:
____________ 2.
Start time: ________ End time: ________
3. Please select the note type:
☐
Individual
☐
Group – answer fields 3a and 3b: 3a. ____ Number of Counselors
3b. ____ Number of Patients
PATIENT INFORMATION
4. Name (Last, First, and Middle):
5. Date of Birth (mm/dd/yyyy):
6. Medi-Cal or MHLA Number:
7. Address:
8. Gender:
9. Preferred Language:
10. Race/Ethnicity:
11. Phone Number:
Okay to Leave a Message?
☐
Yes
☐
No
PROVIDER AGENCY
12. Name:
13. Contact Person:
14. Phone Number:
15. Address:
16. Fax:
17. Email:
GIRP FORMAT
18. G - Goal
Patient current
focus
and/or
short-term
goal,
based on the
assessment
and
treatment
plan.
I – Intervention
Provider methods
used to address the
patient statements,
the provider
observations, and the
treatment goals and
objectives.
Revised 9/5/17 2
R
- Response
The patient response
to intervention and
progress made
toward individual
plan goals and
objectives
P - Plan
The
treatment plan
moving
forward,
based on the
clinical information
acquired and the
assessment.
19. If the patient's preferred language is not English, were linguistically appropriate services provided?
Yes ☐
No
☐
If no, please explain:
20. Provider Name:
21. Signature:
22. Date:
23. Additional Provider Name if applicable:
24. Signature:
25. Date:
This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable
Welfare
and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of this information for further disclosure is prohibited
without the prior written authorization of the patient/authorized representative to who it pertains unless otherwise permitted by law.
EXTERNAL SAPC REVIEW This section will include communication between SAPC and the agency/provider.
Comments:
Assigned Staff:_________________
_________ Reviewed by: ________________________ Signature: _______________________ Date: _______________
INTERNAL SAPC USE ONLY This section is reserved for internal SAPC use only.
Comments:
Assigned Staff:__________________________ Reviewed by: ________________________ Signature: _______________________ Date: _______________
Revised 9/5/17 3
PROGRESS NOTE INSTRUCTIONS
PROGRESS NOTE TYPE
1. Please enter the date
2. Please enter the start and end time
3. Please select the type of progress note. If a group note is selected, the number of counselors present in the group and the
number of patients in the group are required.
PATIENT INFORMATION
4. Enter the patient name in the order of last name, first name, and middle name.
5. Enter the patient date of birth.
6. Enter the patient Medi-Cal or My Health LA (MHLA) number. If the number is not known, leave the space blank.
7. Enter the patient address.
8. Enter the patient gender
9. Enter the patient preferred language
10. Enter the patient race/ethnicity
11. Enter the patient phone number. Check box to indicate if it is okay to leave a message at this phone number.
PROVIDER AGENCY
12. Enter the agency name
13. Enter the contact person
14. Enter the phone number
15. Enter the address
16. Enter the fax
17. Enter the email
NOTE-GIRP FORMAT
18. Enter the progress note information for the individual in the GIRP format
19. Enter any linguistically appropriate services if the patient preferred language is not English
20. Enter the provider name
21. Enter the provider signature
22. Enter the date
23. Enter an additional provider name such as a supervisor, or a second provider present during the encounter.
24. Enter the additional provider signature
25. Enter date
EXTERNAL SAPC REVIEW
This section will include communication between SAPC and the agency/provider
INTERNAL SAPC USE ONLY
This section is reserved for internal SAPC use only.
SUBMIT THIS FORM TO:
Fax: (323)-725-2045
Phone: (626)-299-4193
FOR ADDITIONAL SAPC DOCUMENTATION PLEASE SEE
http://publichealth.lacounty.gov/sapc/NetworkProviders.htm
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Individual SUBSTANCE ABUSE PREVENTION AND CONTROL PROGRESS NOTES (County of Los Angeles Internal Services Department)

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Completed 29 October 2021

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