ABSTRACT
Assessment and care planning are a continuing process and a foundation for good clinical practice. It is a fundamental component within the framework of the systematic approach to the provision of care and interventions. For a systematic approach to health and social care interventions, evaluation of care should be an important component of the process of care. The patient’s treatment journey is based on four overlapping components: Engagement with the service, treatment delivery (including maintenance), community integration (which underpins both delivery and treatment maintenance or completion) and treatment completion. Alcohol and drug misusers with complex needs require assessment that is comprehensive and multi-professional to plan effective care and treatment. Risk assessment and management is a core element of good practice in substance misuse services. Taking a drug and alcohol history is a detailed assessment of the current presentation of an individual’s pattern of using drugs and alcohol. Assessment all too often focuses only on the individual’s negative aspects of substance misuse such as an individual’s weaknesses, risks and problems. Clinical assessment for those with substance misuse and psychiatric disorders is difficult because substance misuse can mask psychiatric symptoms or distort diagnosis.
