Advocacy

Documenting the History of Substance Use in the History and Physical Examination

Adoption Date:
April 1, 1998

Public Policy Statement on Documenting the History of Substance Use in the History and Physical Examination

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Background:

It has been customary in the recording of a patient’s history by physicians and other advanced-degree health practitioners to obtain and document the history of a patient’s use of substances (alcohol, other mood-altering drugs, nicotine, and caffeine) in the Social History section of the History and Physical Examination. Often this documentation is cursory, with few details regarding the specifics of this use, such as exactly which substances were used, how much was used, and what were the associated consequences of that use. This practice also has given the unspoken message that disorders that involve the use of substances, such as abuse and addiction, are social problems, and not addressable through the provision of traditional medical care.

The recent acquisition of research data regarding the causes of addiction supports the fact that substance use disorders, especially addiction (dependence), are multifactorial in their nature, and that one of these factors is often the inheritance of a genetic predisposition to the disease of addiction. Therefore, current thinking indicates that substance use disorders are medical conditions in their own right, and not strictly social in nature. This also indicates that it is appropriate for properly trained and certified medical personnel to provide treatment of substance use disorders.

The American Society of Addiction Medicine (ASAM) recommends that:

1. Questions regarding a patient’s use of substances, and the consequences of that use, should be asked along with questions regarding other medical conditions, and that this data should be recorded in the Review of Systems section of the History and Physical Examination, when the Chief Complaint is not related to a substance use disorder. In the event that the Chief Complaint is related to a substance use disorder, that data should be recorded in the History of Present Illness.

2. All schools which train physicians and other advanced degree health practitioners consistently instruct their students to record the use of substances and the consequences of that use in a section other than the social history, such as the History of Present Illness or in a separate section of the Review of Systems (e.g., substance use).

3. The presence or absence of a family history of substance abuse or substance dependence should be recorded in the Family History section of the History and Physical Examination.

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  1. SAM Barnes Nov 28, 2017 - 08:40 AM

    need a boiler plate, please

     

    Sam T Barnes, MD

    sandsbarnes@charter.net

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