Electronic Medical Records
Smart Phrases for your EMR:
RISKY Alcohol Use
History:
Patient presents today to for their annual physical exam. The patient completed the AUDIT-C for screening for risky and unhealthy alcohol use. They screened positive, with a score of ***. The patient endorses drinking *** drinks per week and *** drinks per sitting, most often. The patient denies drinking for longer than was initiated or in greater amounts than intended. There is not persistent desire to drink and no efforts have been made to cut back. The patient does not spend a great deal of time to obtain or use alcohol. The patient denies craving alcohol. The patient does not have any major failures in fulfilling roles at work or home. There are no physically hazardous activities reported. No withdrawal and no tolerance features are reported.
Assessment and Plan:
Excessive Alcohol Use (F10.10): Patient screens positive for unhealthy alcohol use. Engaged in brief intervention with patient and discussed methods to cut back on use. Patient agreed to reduce alcohol consumption. Monitor annually with wellness visits. Encouraged to return to care if alcohol use increases or the patient has difficulty cutting back.
Alcohol DEPENDENCE
History:
Patient presents today to discuss chronic conditions including diabetes, hypertension and left knee pain. The patient completed the AUDIT-C for screening for risky and unhealthy alcohol use. They screened positive, with a score of ***. The patient endorses drinking *** drinks per week and *** drinks per sitting, most often. The patient endorses drinking for longer than was initiated or in greater amounts than intended. The patient has attempted to cut back, but has not been able to do so and occasionally does endorse craving alcohol. The patient has not yet had any major failures in fulfilling roles at work or home. There are no physically hazardous activities reported. No withdrawal and no tolerance features are reported at this time. No history of detoxification, withdrawal seizures, DT’s, or hospitalizations.
Assessment and Plan:
Alcohol Dependence (F10.2): Patient screens positive for alcohol abuse and dependence. Cognitive behavioral therapy was used to assist patient in addressing use and identifing methods to cut back. Additionally, engaged in motivational interviewing with patient and explored motivators for change. Start naltrexone 25 mg PO daily. Will follow up in 2-4 weeks to monitor for reduction; may follow up sooner if symptoms worsen or difficulty cutting back.
Check back soon to see how to best record screening, interventions, and medical therapies in the EMR. Case descriptions for multiple EMRs are below, with screen shots to help navigate.
We hope to build this out for each EMR so you’ll have this specialized for you! But we will need to get in touch with practices first, to see how this works per practice. Thanks for your patience.
