Addiction Medicine Consult

ملاحظة منتهية

مثال — تم إنشاؤه بواسطة Notat من زيارة نموذجية

Presenting concern:
Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm.

Assessment:
Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed.

Plan:
Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

قالب

Addiction Medicine Consult

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Substance Use History:
(hyphenated list)
- [Substance(s) used: type, amount, route, frequency, duration]
- [Date and time of last use]
- [Previous attempts at abstinence or treatment]
- [Withdrawal symptoms: type, severity, duration]
- [Overdose history: number, circumstances, naloxone use]
- [Complications related to substance use: medical, psychiatric, social]

Past Medical History:
(hyphenated list)

Psychiatric History:
(hyphenated list)
- [Diagnoses, hospitalizations, suicide attempts, self-harm, current symptoms]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Buprenorphine-naloxone 8-2 mg SL BID)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Father: alcohol use disorder)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Other substances: type, amount, frequency]
- [Living situation: who lives with patient, home environment, housing stability]
- [Employment/education status]
- [Legal issues: charges, probation, incarceration]
- [Support system: family, friends, community resources]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance: level of distress, signs of intoxication or withdrawal]
- [Neurological: orientation, tremor, asterixis, pupil size]
- [Other relevant systems: as indicated by history]

Investigations:
(hyphenated list)
- [Investigation results with units] (e.g., urine drug screen, LFTs, CBC, HIV, Hepatitis panel)
- (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary diagnosis or substance use disorder]

#) [Assessment as a numbered item for each substance or issue]
(Hyphenated list with each corresponding plan item on a new line)
- [Withdrawal management]
- [Pharmacotherapy]
- [Harm reduction]
- [Counselling]
- [Referrals]
- [Follow-up]
- [Return precautions]