Last review date 03/02/2023
To locate the Substance Misuse template go to Auto-consultation > ardens CONDITIONS > S - Z > Substance Misuse
If a previous Substance Misuse code has been added to the Patient record, the 
patient status alert will appear in record.
Please note: You can also click on the icon on the patient status alert to open the template.
Substance Misuse Review Tab
Assessment:
The Review, Status & On Programme drop down boxes have all the relevant codes for recording substance misuse on a patients record. Each of these options have a Blue Star next to them which relates to a required field for national reporting.
Key worker - type in the name/contact of any keyworkers. The icon to the right of this field gives access to the Care Team & Relationships template to record a relationship on SystmOne. This will show in the Groups & Relationships node within the record.
Smoking - assign a smoking status by readcode, or access the Smoking or Vitals and Lifestyle template to add BP, Height/Weight etc.
Alcohol - The patients Alcohol status can be added via the drop down box along with links to useful scored assessments such as Audit-C and SADQ.
Withdrawal - if needed select appropriate code. There are also withdrawal scored assessments available for CIWA-B Benzodiazepine Withdrawal Score or COWS Clinical Opioid Withdrawal Scale.
Tools - There is a link to the BBV Risk Assessment template if suspected.
SM + Toxin Levels will show any previous blood results or use Phlebotomy to look at all recent blood test results. Clicking into either of these will also provide access to ICE/T-quest if required.
Impression:
Record the current Level of substance misuse, or choose use New Coded Entry to search for alternative codes.
Management:
Goals - Assign a treatment goal, use the Goals template to record more detail around this. The Driving template allows you to record any advice given with links to a Patient Letter and letter to the DVLA.
IAPT - Contains signposting or referral codes. The Mental Wellbeing Leaflet includes local services the patient can contact (if using Ardens Pro Package) or national services.
Leaflets - Contain useful hyperlinks that can be copied and sent via text/email.
Lifestyle - The Lifestyle Wellbeing Leaflet again provides local services the patient can contact. Med3 & Letters allows you to view all previous Med3 certificates or generate a new Med3.
You can also view patient letters within this template without having to close and look at Communications & Letters in the record.
A Substance Misuse Shared Care Treatment Agreement is available as a Word document, click the document named Agreement to open:
Medication:
There a 3 formularies available for prescribing; Alcohol Misuse Formulary, Opioid Misuse Formulary and Anxiolytics Formulary.
Acute Intoxication Tab
Review:
There is a short cut to the SystmOne Panic Button if needed.
If require, convenient links are available to the Epilepsy template, Head Injury & Concussion and Sepsis Risk Stratification.
The Observations template allows you to record Obs at intervals:
Investigations - Each of the templates available here allow you to either capture new data or look at historical data. Click Phlebotomy to view recent blood test results or add a new request, there is a shortcut link to Ice/T-quest.
Substance Misuse & Toxin Levels will show relevant blood results or allow you to manually add any new results.
You can record an ECG being taken or view past ECG results.
Plan:
Decisions & Mental Capacity provides guidance on assessing the capacity of the patient to consent and enables relevant coding.
The Ambulance & Transport template allows you to document the information in detail if an ambulance has been requested.
The Emergencies & Resuscitation link provides a view of relevant information including any DNACPR status and hyperlinks to the Resuscitation Guidance Council and which gives information on life support for adults & children.
Type & Route
This section allows you to add any history of substance misuse and the route and includes medical drawings should you wish to add detail of injection sites.
Clinical Reporting
Relevant reports are available by going to Clinical Reporting > Ardens Ltd folder.
Go to Contracts | 2022 23 | Local Contracts > Annual All > 2022-23 Substance Misuse
There are 4 separate reports available here:
Register - On programme
Review - Done + not on SM programme
Review - Done + on SM programme
Screening - Done
Also from the Ardens Ltd folder go to Lifestyle > Substance Misuse | Activity Last Month or Performance Indicators or Registers
