• Document specific drug used/abused
• Frequency (use, abuse, dependence, in remission)
• State “no related complications,” when applicable
• Specify intoxication/withdrawal as “uncomplicated” or “with delirium"
• Document any related mood disorder (anxiety or delirium)
• Document any delusions, hallucinations, psychotic disorder, anxiety, sleep disorders, sexual dysfunctions or other related conditions
• List any treatment provided (detoxification services, counseling, psychotherapy, medication management, pharmacotherapy)
• Any withdrawal symptoms
• For tobacco, mode of nicotine use (cigarettes, chewing tobacco, pipe and/or gum)

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

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