SMH Addition Medicine Consult

OVERALL_INSTRUCTIONS

Chief Complaint

[Insert brief statement of reason for addiction medicine consult]

Template

Date of consult: [Insert Date] Referring Physician: [Insert Referring Physician Name] Consulting Physician: [Insert Consulting Physician Name] Dear Dr. [Referring Physician Last Name], ID/HPI: [Insert identifying information and history of present illness] RFR: [Insert reason for referral] SUBSTANCE USE HISTORY: Alcohol: - First exposure: [Insert details] - Usual amount/pattern: [Insert details] - Last use: [Insert details] - History of withdrawal: [Insert details] - History of consequences: [Insert details] - History of treatment: [Insert details] - History of relapse prevention: [Insert details] - Relapse prevention Rx?: [Insert details] - PAWSS: [Insert score] Stimulants: - First exposure: [Insert details] - Current amount/pattern: [Insert details] - Last use: [Insert details] - History of withdrawal/consequences: [Insert details] - History of treatment: [Insert details] Opioids: - First exposure: [Insert details] - Take Home Naloxone kit: [Yes/No] - Amount/pattern: [Insert details] - History of overdose: [Yes/No] - Last use: [Insert details] - History of OAT: [Insert details] - Suboxone: [Yes/No] - Methadone: [Yes/No] - Kadian: [Yes/No] - iOAT: [Yes/No] - Highest dose: [Insert details] - Longest duration: [Insert details] - Prescribed safer alternatives: [Insert details] Nicotine: - Age: [Insert details] - Amount: [Insert details] - Previous quit history: [Insert details] - Cessation medication: [Insert details] - Stage of change: [Insert details] Other: - Cannabis, Benzodiazepines, GHB, Hallucinogens, Inhalants: [Insert details] HARM REDUCTION: - Injection drug use: [Present/Past/Never] - Access to safe supplies: [Yes/No] - Use at supervised consumption site: [Yes/No] - OPS use: [Yes/No] - Lifeguard App: [Yes/No] - Uses with others or others nearby: [Yes/No] - Uses test doses: [Yes/No] - Take Home Naloxone: [Yes/No] - Other safety strategies: [Insert details] SOCIAL HX: - Housing: [Insert details] - Employment/Finances: [Insert details] - Family/Children/Relationship: [Insert details] - Other: [Insert details] PMHx: [Insert past medical history] Family Hx: [Insert family history] LNMP: [Insert last normal menstrual period, if applicable] MEDICATIONS: [Insert current medications] ALLERGIES: [Insert allergies] INVESTIGATIONS: - UDS: [Insert details] - Cr, GFR, Na, K: [Insert details] - GGT, AST, ALT, ALP: [Insert details] - Hgb, MCV: [Insert details] - Tox: [Insert details] - INR, Plt, Albumin: [Insert details] - ECG: [Insert details] PHYSICAL EXAMINATION: - BP: [Insert value] - HR: [Insert value] - RR: [Insert value] - SpO2: [Insert value] Subjective Complaints: - Agitation: [Yes/No] - Diaphoresis: [Yes/No] - Restlessness: [Yes/No] - N/V/D: [Yes/No] - Piloerection: [Yes/No] - Yawning: [Yes/No] - Tremor: [Yes/No] Mental Status: [Insert details] HEENT: Coryza [Yes/No] Pupils: [Insert mm] Resp: [Insert details] CV: [Insert details] Abdo: [Insert details] Jaundice/Icterus: [Yes/No] Ascites: [Yes/No] MSK: [Insert details] DERM: Track marks [Yes/No] Other: [Insert details] IMPRESSION/PLAN: - Opioid Use Disorder: [Active/Remission] [Mild/Moderate/Severe] [Early/Sustained Remission] [Comments] - Stimulant Use Disorder: [Active/Remission] [Mild/Moderate/Severe] [Early/Sustained Remission] [Comments] - Alcohol Use Disorder: [Active/Remission] [Mild/Moderate/Severe] [Early/Sustained Remission] [Comments] - Cannabis Use Disorder: [Active/Remission] [Mild/Moderate/Severe] [Early/Sustained Remission] [Comments] - Nicotine Use Disorder: [Active/Remission] [Mild/Moderate/Severe] [Early/Sustained Remission] [Comments] - Benzodiazepine Use Disorder: [Active/Remission] [Mild/Moderate/Severe] [Early/Sustained Remission] [Comments] - Other: [Insert details] Consider: Acute withdrawal management, stabilization and relapse prevention, pharmacological and psychosocial support options, harm reduction. Next appointment: [Insert date or details]