Substance Use History provides documentation of miscellaneous substances that the patient has used.

 

1.Complete the information in the sections below, as needed.

 

•Substance Use: Defines the patient's substance use.

oUse may be documented as Never, Rare, Occasional, Frequent, Addiction, and Recovering Addiction.

oThe Usage Routes may be documented as Oral, Smoking, Intranasal, Inhalation, Subcutaneous, Intravenous, or Other. Selecting Other allows free-text entry.

oThe Types available for documentation are Cocaine, Methamphetamine, Heroin, Marijuana, Prescription Drug Abuse, or Other. Selecting Other allows free-text entry.

oFrequency defines the number of Times per Day, Times per Week, or Times per Month that the patient uses the substance. The number of years of Substance Use may be documented along with the Substance Use Start Date and Substance Use End Date.

oUsage Amount may be documented as Increasing, Decreasing, or Unchanged.

 

•Alcohol: Defines the patient's current alcohol use.

oUse may be documented as Never, Rare, Occasional, Frequent, Binge Drinker, In Recovery, Quit, or Abuse History. You can select multiple options.

oType provides a way to define the type of alcohol (Beer, Wine, and Liquor).

oThe number of Drinks per Day, Week, or Month may be documented in Frequency. LOINC code is attached.

oScreening date may be given. Current date will be the default but may be changed.

oDuration will define the number years they have used alcohol. The start and end dates may also be recorded.

 

•Caffeine Use: Caffeine Use may be documented with the number of Servings per Day of Coffee, Tea, and Soda/Pop consumed.

 

2.Once documentation is completed, select Save.

 

NOTE: If information is not saved, the system will prompt, "Are you sure you wish to exit without saving?"