Substance Use Withdrawal Management (SU WDM) & Recovery - Intake Form – Profile EMR User Help

Background

VCH staff who work at START, Vancouver Detox Centre, South Vancouver Withdrawal Management, and select Support Recovery sites will document their intake assessments in the SU WDM Recovery Intake Assessment form. This form will standardize intake documentation across the mentioned programs.

Intake Assessment Form

The Intake Assessment form can be used by two clinicians to document their intake assessment. Each program will have a slightly different intake workflow:

START & South Vancouver Withdrawal Management: Nurses and physicians will document in one Intake form.
VDC and Support Recovery: Fellows and physicians will document in one Intake form

The first clinician opens the Intake Assessment form, documents, marks the form status as “Parked”, and then saves it. The second clinician opens the same form, documents, marks the form status as “Completed” and then saves it.

Generate the Intake Assessment Form

In the New Encounter, enter the program specific typing template to launch the form.

SU WDM & Recovery Program:	Typing Template Code:	Title Encounter Note:
START	starti\	START Intake
South Vancouver Withdrawal Management	svwmi\	South Vancouver Withdrawal Management - Intake Assessment
VDC	vdci\	Vancouver Detox Center Intake
Support Recovery	To be determined	To be determined

It will automatically title the Encounter note:

Note: the form can also be opened from the New Encounter > Actions Panel > Forms.

Document the Assessment

There are two tabs on this form: Assessment and POC/Treatment Plan. The form defaults the client's name, admission date to today (can be edited), and the logged in user in the Assessment Conducted by field.

Assessment (Tab 1)

To begin, select the location from the Location drop down menu. It will default the location's address details.

Assessment Sections:

There are free text sections. Enter you assessment in the appropriate fields. Type s\ to record your signatures and time stamp.

Medication Reconciliation:

Record that med rec was completed using either the Paper Medication Reconciliation completed or the Pharmanet reviewed checkboxes

Problem List and Allergies

Problems:

This section displays a list of active problems from client's Problem list

New - to add a new problem. This opens the Problem-Diagnosis window (Search for the problem that you need to add and click OK)
Edit - to edit an existing problem on the list
Goto Problems - Opens the Problems tab in the medical record

Allergies:

New - to add a new adverse reaction. This opens the Problem-Adverse window (Search for the adverse reaction that you need to add, update Nature field and click OK)
Edit - to edit an existing adverse reaction on the list
Goto Problems - Opens the Problems tab in the medical record

Supplementary Assessment Scores

You can enter the assessment scores for the following:

Clinical Opiate Withdrawal Scale (COWS)
Clinical Institute Withdrawal Assessment for Alcohol Use (CIWA)
Prediction of Alcohol Withdrawal Severity Scale (PAWSS)
Benzodiazepine Risk Assessment

The Substance Use Grid Button will launch the form. Once complete, it will be saved as a link in the Encounter. Note: to go back to the Intake Form, navigate to Windows and select Intake Form

POC/Treatment Plan (Tab 2)

The following POC tests can be documented on Tab 2 of the Intake Assessment form:
Rapid UDS Results
Pregnancy Test
Breathalyzer Test

Treatment Plan:

You can record the treatment plan for each Problem:

Form Status

If you are the last person to document in the Intake Form, make sure you change the status to Complete.

Marking the Assessment as "Complete" and Saving the Form:

After the form is saved and closed, text from the form is pushed to the Encounter note. You can edit/format the text in the Encounter.

Saving/Printing the Intake Assessment Form

There are four buttons to save/print the assessment form:

Print, Save, Close - Clinicians use this button. When they finish their documentation, it will write the assessment to the Encounter note and then print the assessment
Print - This button can be used to print the form from Encounter's view after the assessment is complete and Encounter has been saved
Save & Close - Clinicians use this button to save the form & write the assessment to the Encounter notes without printing
Print this Page - It will print the current page

Printing a completed assessment from the Encounters tab:

Making Edits to the Intake Assessment Form

Parked Form:

Open a New Encounter, enter the typing template code to open the intake assessment form. Make the edits then save. Only the updates will write to the Encounter note.

Complete Form:

Completed forms cannot be updated. If you need to add additional information, document a New Encounter note.

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