Document Alcohol or Drug Use History
- On the Confidential - Alcohol/Drug template, go to the Alcohol Use section.
- Enter the age on the Age Alcohol Use Began numeric keypad in the Age Started field.
- Select the No or Yes option for the following queries:
- Sought treatment for alcohol abuse
- Involved in a 12-step program
- Have you had withdrawal problems, seizures or blackouts from alcohol or drugs
- Emergency medical attention required due to intoxication
- Family Hx of alcoholism
- To document treatment, enter the date of the last drug treatment, and the number of times the patient received drug treatment.
- Under Drug Use/Abuse, select an option to indicate if the patient uses drugs.
- If the selected option is No, no other documentation is required in this section.
- If the selected option is Yes or Formerly, document the age at which patient started using drugs, drug type, frequency of drug use and route.
- Select the Quit check box to indicate that the patient used the associated drug formerly and has quit.
- Select either Yes or No for the following queries.
- Sought treatment for drug abuse
- If Yes, enter the number of times the patient was treated and the date of the last drug treatment. Select the Outpatient or Inpatient check box to document the type of treatment.
- Involved in a 12-step program
- If Yes, select a check box to indicate if the patient is involved currently or was involved previously.
- Emergency medical attention required due to drug use
- If Yes, document the number of times patient was treated.
- Family history of drug use
- If Yes, document the patient's relationship to the family members with a history of drug abuse.
- Sought treatment for drug abuse