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. Open the Histories template.
3. In the Social panel, select the Confidential History link.
   The Confidential - Alcohol/Drug template opens displaying the links to the confidential templates, in the left pane.

   

4. In the Alcohol Use section, enter the age at which the patient had started drinking alcohol.
5. Select Yes or No to 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.
6. Select Yes or No to indicate if the patient is involved in a 12-step program.
   • If you select Yes, select Currently or Formerly.
7. Select Yes or No to indicate if the patient has had withdrawal problems, seizures, or blackouts from alcohol or drugs.
8. Select Yes or No to 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.
9. Select Yes or No to indicate if there is any family history of alcoholism.
   • If you select Yes, then select a family member from the list.
     Note: To select multiple family members, you can select the other three fields.
10. Enter the number of times in the past year the patient has had 4 or more drinks in a day.
11. Select OK.