Document a Patient's Drug Use

You can document the drug use 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 Drug Use/Abuse section, indicate the patient's use of drugs.
   • If you select No, no other documentation is required in this section.
   • If you select Yes or Formerly, enter the age at which patient had started using drugs, the drug type, frequency of drug use, and route.
   • If the patient had used the drug earlier and has now quit, select Quit.
5. Select Yes or No to indicate if the patient has sought treatment for drug abuse.
   • If you select Yes, enter the number of times the patient is treated and the date of the last treatment. Select Outpatient or Inpatient to indicate the type of treatment.
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 required emergency medical attention due to drug use.
   • If you select Yes, enter the number of times the patient was treated for drug use.
8. Select Yes or No to indicate if there is any family history of drug abuse.
   • If you select Yes, enter the patient's relationship with the family members with a history of drug abuse.
9. Select OK.