Clinical documentation is an essential component of patient care, especially in addiction consults. As a nurse practitioner, it is crucial to ensure that all aspects of a patient's addiction history and treatment plan are meticulously recorded. This guide will walk you through the proper structure and format for an addiction consult document, using a standardized template to ensure clarity and completeness.

Reason for Referral

The document begins with a succinct statement detailing why the patient has been referred. For example: "The patient, John Doe, was referred by Dr. Smith for evaluation and management of substance use disorder." This section provides context and sets the stage for the consultation.

Patient Identification

Next, include identification details: "John Doe is a 35-year-old male with a history of hypertension and diabetes, presenting for substance use evaluation." This section includes basic demographic information and the reason for the current evaluation.

History of Presenting Illness

This section describes the patient's current issues: "John has been experiencing increased cravings and difficulty managing his substance use, particularly with opioids and alcohol." Clearly outline the symptoms and concerns that brought the patient to seek help.

Substance Use History

Document each substance used, including start age, usage patterns, and any treatment attempts. For instance, "Nicotine: Started smoking at age 16, smokes first cigarette within 10 minutes of waking, has tried nicotine patches, smokes up to 20 cigarettes a day." Repeat this for each substance to provide a comprehensive history.

Social History

Include relevant social factors affecting the patient: "John lives alone, works as a freelance graphic designer, accesses harm reduction supplies, has been incarcerated for 6 months, does not engage in sex work, family doctor is Dr. Lee." This gives insight into the patient's environment and support systems.

Addiction Treatment History

Record previous treatment endeavors: "John has been to detox twice and attended an in-patient drug and alcohol treatment center once." This helps in understanding past interventions and planning future treatment.

Pharmanet Summary

Detail the patient's pharmacy usage: "Uses ABC Pharmacy, receives weekly dispensing of methadone, prescribed by two doctors, missed doses occasionally." This section is crucial for medication management and compliance checks.

CIWA Score

Provide the Clinical Institute Withdrawal Assessment score and relevant symptoms: "CIWA score of 8, primarily from tremors and anxiety, responds well to benzodiazepines for alcohol withdrawal." This quantifies withdrawal severity.

Medications in Hospital

List current medications: "Currently receiving methadone and Suboxone, has received 30 mg of methadone in hospital." This ensures continuity of care during hospital stays.

Physical Exam and Investigations

Summarize physical findings and investigations: "Vital signs: BP 130/85, HR 78, RR 16, Temp 98.6°F. Lab values: CBC normal, LFTs elevated. ECG: normal, QTc 420 ms." This section provides an overview of the patient's current physical health.

Assessment and Plan

Conclude with an assessment and treatment plan: "John is being consulted for opioid and alcohol use disorder, both active. Plan: 1. Continue methadone maintenance therapy. 2. Initiate naltrexone for alcohol use disorder. 3. Monitor blood pressure and glucose levels. 4. Provide counseling and support for substance use." This outlines the diagnosis and proposed interventions.

Documenting patient interactions can be time-consuming, but AI medical scribes like Notis AI Medical Scribe offer a solution. Notis uses advanced voice-to-text technology to create structured SOAP notes, which can save nurse practitioners substantial time on documentation tasks.

By automating the transcription of clinical notes, Notis reduces the time spent on documentation by up to 80%. This allows healthcare providers to focus more on patient care. The integration through familiar platforms like WhatsApp makes it user-friendly, and its high accuracy ensures reliable documentation.

For nurse practitioners specializing in addiction treatment, this means more time to engage with patients and less time on administrative burdens. As a tool that supports 56 languages, Notis caters to diverse patient populations, making it a versatile choice for medical professionals worldwide.

In conclusion, mastering the documentation of addiction consults is crucial for effective patient care. By leveraging AI medical scribes, nurse practitioners can enhance efficiency, accuracy, and ultimately, patient outcomes.