Monday, March 10, 2008

VA counselor Smith's medical report on C. Mueller

9, 17, 2007 Loma Linda VA hospital. Jerry Smith counselors medical report.

MEDICAL RECORD Progress Notes

NOTE DATED; 09/17/2007 13:55

LOCAL TITLE; BHOST/CHEM DEP/PROGRESS NOTE

VISIT: 09/17/2007 09:00 ATUG PROBLEM GROUP

The pt attended Problem Group facilitated by Jerrold Smith, Addiction Therapist. This group meets five days a week. There were nineteen patients in Attendance and the group was ninety minutes in duration, also in attendance: one nursing student.

The goal of this group is long term sobriety and the
objective is to work through the issues that contribute to the addiction.

Axis I: cannabis dependence

Today’s focus was on , open discussion. Pt was voted out by the gr0up because of his accusing another pt of stealing and his calling the same pt a beggar, pt didn’t believe his behavior was out of line. Pt was told he could return in seven days. The pt stated he would go to 2NE and use the hospital for whatever he could get.

Level of participation in the group: [Non of the below six levels where marked]

No participation, Pt quiet throughout the group

Low level of participation in discussion, making brief comments

Moderate level of participation, making some appropriate comments

High level of participation, appropriate participation in the group discussion.

Over active participation, trying to dominate the group.

Insensitive to other group members.

Veterans may have a copy of this note upon completion of consent to release of information.

Signed by: /es/ JERROLD T SMITH
Addiction Therapist
09/17/2007 14:16




MUELLER, CARL G Loma Linda VAMC Printed: 12/17/2007 08:49
(Social # here) Pt Loc: OUTPATIENT Vice SF 509