Addiction treatment software: from intake to aftercare, one client file
Addiction treatment software has to follow a person through months, not a single appointment: an intake, a programme with goals, groups, tests, daily doses and aftercare that must not quietly lapse. This guide sets out what the record should hold, follows one client through OPALEVI, and says plainly where OPALEVI stops.
Key takeaways
- In a treatment centre the programme is the spine: sessions, groups, drug tests and medication orders are filed under it.
- Drug tests belong in a log with a status, from collection to review, not in a session note.
- OPALEVI adds up the AUDIT-C and records what the team observes; it charts no withdrawal scale, calculates no dose and judges nothing.
- Addiction records are sensitive: in OPALEVI they start closed to the rest of the clinic, and reception reads no clinical record unless you allow it.
Signs an addiction service has outgrown paper and a general clinic program
Many services start with a binder per client, a whiteboard for groups and a dose sheet on the nurses' desk. A general clinic program replaces only the binder. The strain shows:
- Nobody can say who is on which programme. Dates and key workers live in three files, and a programme ending next week is noticed after it ends.
- Group attendance sits on a loose list. Six relapse-prevention groups or two? Someone counts by hand.
- Test results float. A positive screen is mentioned in a note, and nobody is sure it was ever reviewed.
- The dose sheet is the only proof. Who gave the 08:00 dose, and who saw it taken, is whatever was initialled.
- Aftercare depends on memory. The check-in a month after discharge happens if someone remembers it.
In addiction treatment the unit of work is the programme, and everything that happens to a client belongs to one.
What an addiction treatment record should hold
Agree first on what a client's file must answer, on paper or in any program:
| Field | Why it matters |
|---|---|
| Main substance, other substances and route | The basis of the plan; an injecting route changes the examination. |
| Last use and the pattern of use | In the client's own words, not a number nobody measured. |
| A screening questionnaire, scored the same way each time | Comparable from intake to discharge. |
| The programme: type, dates, key worker, goals | Who is responsible, until when, and what success was agreed to be. |
| Drug tests with specimen, method and status | A result counts once it is reviewed; an observed collection is worth recording. |
| Every dose given, refused, held or missed | With the time, the person who recorded it and a witness where one was present. |
| Group attendance and incidents | Engagement over weeks, and events the team must review. |
| A safety plan and an aftercare plan | What the client keeps, and what happens after they leave. |
From intake to an active programme, step by step, in OPALEVI
Registered as a centre in OPALEVI for addiction treatment centers, the screens say Clients and sessions. Here is one outpatient intake; bold words are on-screen labels.
The booking
Reception registers the client and books the intake with Add appointment, where Email the client a reminder the day before can be ticked when the file holds an email address.
Vital signs
A nurse records the vital signs and presses Mark ready for the clinician; the clinical record is the clinician's to write.
Substance and use
Under Substance and use, choose the Main substance and route, enter Last use and describe the Pattern of use in prose. For alcohol, answer the three questions of the AUDIT-C (alcohol use); OPALEVI adds up the total and shows how many were answered.
Monitoring and circumstances
Monitoring takes the Last screen, the Screen result and Withdrawal notes; Circumstances takes Social support, Housing and work and Risk and safety, all in the clinician's words.
The programme
On the client file's Programme tab, Start a programme: its type (outpatient, intensive outpatient, residential, detoxification or aftercare), a name, dates, the Key worker and up to twenty Goals. The session's Programme panel files it there.
The plan the client keeps
Fill in Safety plan and treatment plan together, then print the Safety and coping plan from the session header.
Injection sites and skin findings draws the figure from the client's recorded sex; each mark keeps a finding in words and a size in millimetres. Every session starts empty: earlier sessions are shown beside today's, never copied into it.
The AUDIT-C is the only questionnaire here: no withdrawal scale is charted, and its total carries no band or advice. The Last screen is typed; tests live in their own log. And the Crisis and emergency numbers are typed for the client's country, since OPALEVI fills in none.
Groups, drug tests, the medication round and incidents
These come with the practice type, not a department, together with rooms and beds for detox and residential stays.
Groups and their roll
Under Groups, Schedule a session sets the title, kind (group therapy, relapse prevention, family session and others), programme, room and lead. The roll opens half an hour before the start, with a private note per participant. Mark as held closes it with a Group summary, which should name nobody. Attendance counts towards each client's programme, and leads see My groups today.
Drug tests, from collection to review
Record a test asks for a Point-of-care test or a laboratory one, the specimen, Observed collection, a Chain-of-custody reference and a result per substance; The rest are negative completes the common panel. A clinician with review rights adds a note and presses Mark as reviewed; the test is then final, and a wrong result needs a new test.
On the client's Drug tests tab, Results by substance lays the last twelve tests side by side. Any positive makes a test positive; OPALEVI connects to no test reader and reads nothing into a result.
The medication round
A doctor writes a New order on the client's Medication tab (medicine, dose, route, times or as needed) and saves it with Add to the round. The Medication round lists the shift's doses room by room; each is recorded once as given, refused, held or missed, and Time and witness adds a colleague who saw it. Due doses also wait under Doses due now on Today, and a given dose linked to stock takes one off the shelf. OPALEVI calculates no dose: the round records what happened to the prescriber's order.
Incidents
Report an incident records when, where, the kind (substance use, self-harm, aggression and others), a severity and what was done. A major or critical one gives the administrators a task at once; they Take into review and Close with this outcome, and open ones wait under Incidents to review.
Ending a programme and keeping aftercare on the calendar
The programme card shows its goals, each met or set aside, and Filed under this programme: every session, group, test and order of the course.
End the programme
End programme asks whether it was completed or discontinued, the date and the reason, then a Discharge summary and an Aftercare plan.
Plan the check-ins
Under Aftercare and relapse prevention, Plan follow-ups creates a task per interval, from one week to twelve months after the end, assigned to the key worker.
Book and write the note
Book the first check-in from the card. The starter template in Discharge notes has headings for programme, outcome, medication and aftercare.
Confidentiality: who in the centre reads what
Clients often fear that the desk, or a relative on the staff, reads their file. OPALEVI answers in layers:
- The department. Record privacy, under Settings → Department setup, starts at The department for addiction treatment: its staff, the clinician the record is assigned to and the administrators. A general practitioner of the same clinic sees that a record exists, marked Restricted, but not what it says. The whole clinic and Only the clinician are the other choices; a centre with a single department chooses between Automatic and Only the clinician.
- Reception and finance. Reception books and takes payment, and reads no clinical record until the clinic ticks Reception may see patients' visit history. Finance never does.
- Each clinician. Doctors may only access their own patients narrows lists, the round and the test log to the doctor's own clients.
- Groups. Only staff who may read the clinical record see participants' names.
Roles can be adjusted permission by permission, and the Change history keeps a before-and-after of every save. For risk notes and weekly therapy, read mental health practice software; for residential shifts, nursing home software. Clients from family medicine arrive through Refer to a department; see general practice software. Liver follow-up after heavy drinking, MELD included, is in gastroenterology software.
Questions to ask before choosing addiction treatment software
Ask every vendor, OPALEVI too, during a trial.
| Question | A good answer | OPALEVI |
|---|---|---|
| Is the programme a record of its own? | Type, dates, key worker, goals, an ending. | Yes: Programmes, with a caseload view. |
| Are drug tests reviewed, not just typed? | A status from collection to review. | Yes: reviewed tests are final. |
| Does it read results from a test cup or analyser? | A tested connection, or a clear manual route. | No: results are entered by the team. |
| Is every dose accounted for? | Given, refused, held or missed, with who and when. | Yes: the Medication round, with a witness. |
| Does it chart withdrawal scales? | Validated scales, scored the same each time. | Partly: AUDIT-C only, added up; no withdrawal scale. |
| Does it calculate doses or tapering? | Clarity about what it calculates. | No: orders are typed by the prescriber. |
| Are addiction records closed to the rest of the clinic? | A per-department privacy choice. | Yes: they start at The department. |
| How does the price grow? | Known before signing, whatever the caseload. | Per staff member; clients and sessions are never counted. |
Prices are on the pricing page, every module is on the features page, and the addiction treatment department page lists the record's fields.
Your first week
Register the centre
Choose addiction treatment; three departments come ticked (addiction treatment, psychology and psychiatry, general practice), and any can be unticked.
Prices, letterhead, team
First steps on Today lists the set-up: Add your services and prices (each department arrives with a few starter services to rename and price), Set up the report letterhead and Invite your colleagues, each with a role.
Programmes before groups
Register your first client, start their programme, then schedule this week's groups so the first roll counts towards it.
Name the key worker on day one
A programme without one shows as “No key worker”. Assign one at the start, and the aftercare tasks know whom to go to.
Frequently asked questions
What is addiction treatment software?
A program that keeps an addiction service's work in one place: each client's record and programme with goals and a key worker, individual and group sessions, drug tests through to review, every dose, incidents and the aftercare plan. It replaces binders and dose sheets; clinical decisions stay with the team.
Does OPALEVI include withdrawal scales such as CIWA-Ar or COWS?
No. The addiction record charts one questionnaire, the AUDIT-C, whose three answers OPALEVI adds up without giving a band or advice. Withdrawal is recorded in the clinician's own words under Withdrawal notes; leaving withdrawal scales out of the record was a deliberate choice.
Can reception see clients' clinical notes?
Not unless the clinic allows it. Reception books and takes payment but reads no clinical record until the setting that lets it see visit history is ticked; finance never can. Addiction records also start limited to their department, so other clinicians see only that a restricted record exists.
Does it work on tablets and phones?
Yes. OPALEVI runs in a current browser on any computer, tablet or phone and needs no installation; on small screens its menu sits at the foot of the page. Nurses can record each dose on a tablet as they walk the round, room by room.
Can we try it before paying?
Yes. Registering as an addiction treatment centre opens a free trial, no card. Try it with a test client: start a programme, schedule a group, record a test. Should it end without a plan, you pay nothing, and the files stay open to read.
How is OPALEVI priced for a treatment centre?
You pay for the team, not the caseload: one seat for every colleague whose account is active, and a yearly plan costs less per month. Clients, sessions, programmes and tests are never counted. Today's prices are on the pricing page.
