Level of Care Transition Documentation

Clinical form to document reassessment, ASAM continued service criteria, transfer criteria, and the rationale for transitioning a patient between levels of care.

Patient and Encounter Details

• Patient Identifier
  Use the internal patient ID or medical record number. Do not enter SSN.
• Encounter Date
• Current Level of Care
• Reassessment Type

Clinical Reassessment

• Current Clinical Concerns
  Summarize the symptoms, risks, or functional concerns relevant to the level of care decision.
• Current Risk Level
• Substance Use Status
• Functional Status
• Summary of Clinical Change Since Last Review
  Describe what has changed since the last assessment, including improvement, deterioration, or new concerns.

ASAM Criteria Review

• ASAM Dimension 1: Acute Intoxication and/or Withdrawal Potential
• ASAM Dimension 2: Biomedical Conditions and Complications
• ASAM Dimension 3: Emotional, Behavioral, or Cognitive Conditions
• ASAM Dimension 4: Readiness to Change
• ASAM Dimension 5: Relapse, Continued Use, or Continued Problem Potential
• ASAM Dimension 6: Recovery/Living Environment
• Are continued service criteria met at the current level of care?
• Are transfer criteria met for a different level of care?

Transition Decision and Rationale

• Transition Decision
• Clinical Rationale
  Explain the rationale for the decision, including ASAM criteria, risks, supports, and treatment response.
• Barriers or Risks Considered
• Planned Receiving Level of Care or Program

Plan, Consent, and Attestation

• Next Steps
  List referrals, follow-up timing, safety planning, handoff actions, and any required monitoring.
• Patient Notified of Transition Plan
  Confirm whether the patient was informed of the decision and plan.
• Consent and Disclosure Notes
  Document any consent, privacy disclosures, or information-sharing limitations relevant to the transition.
• Clinician Name
• Clinician Signature
• What happens after I submit