Document a Patient's Alcohol Use

You can document the alcohol consumption details of a patient on the Confidential – Alcohol/Drug template.

1. Open NextGen® Enterprise EHR.
2. To open the Confidential – Alcohol/Drug template, do one of the following:
   • In the Social panel on the Histories template, select the Confidential History link.
   • In the History Summary panel on the Intake template, select the Confidential link.

   

3. In the Alcohol Use section, enter the age at which the patient had started drinking alcohol.
4. Indicate if the patient has sought treatment for alcohol abuse. If you select Yes, then do the following:
   1. Enter the date of the last treatment for alcohol abuse.
   2. Enter the number of treatments taken for alcohol abuse.
5. Indicate if the patient is involved in a 12-step program.
   • If you select Yes, select Currently or Formerly.
6. Indicate if the patient has had withdrawal problems, seizures, or blackouts from alcohol or drugs.
7. Indicate if the patient has required emergency medical attention due to intoxication.
   • If you select Yes, enter the number of emergency treatments taken for intoxication.
8. Indicate if there is any family history of alcoholism. If you select Yes, do the following:
   • Select a family member from the list.
     Note: To select multiple family members, select the other three fields.
9. Enter the number of times in the past year the patient has had 4 or more drinks in a day.
10. Select OK.