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Controlled Substance History of Present Illness (HPI) Quick Reference Guide

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With this Quick Reference Guide, the user will learn how to use the Controlled Substance (HPI) template. Within this template, users will be able to do the following:

  • Add or Search an Assessment.
  • Access the CURES website link.
  • Access other helpful resources

This template acts as a guide for patients that are on Controlled Substances.

Adding Assessments

With the assumption that the user has opened an encounter. The Controlled Substance (HPI) template can be accessed when opening the *INTAKE MG or *SOAP MG templates.

  1. Click the Controlled Substance link.
  2. Select New or Refill radio button
  3. Select a Diagnosis from the Billing History Diagnosis grid, then select current Status.
  4. If Diagnosis is not available, use the IMO (Problem) button, to search for Diagnosis.
  5. Selected Diagnosis along with Status will appear in Today's Assessments grid.
  6. The Diagnosis can be removed, by selecting the Diagnosis from the Today's Assessments grid and clicking Remove.
  7. Clicking the Status field allows the Assessments status to be updated.

Using the Controlled Medication Rx Template

With this template, users will find it easy to document pertinent information. In addition, this template provides a guide for safely prescribing Controlled Substances.

  1. Click the CURES link to sign into the site, then click in field to select date.
  2. Click in the UDS field to select date
  3. Click in the Agreements field to select a date.
  4. Additional comments can be recorded in the available Comments field.
  5. Screening Tools offer links to additional resources
  6. Click Save & Close

The Agreements date field will auto-populate once the Contract Reviewed box is selected on the Document and Letters MG template.

Controlled Substance Agreement

With the assumption that the user has knowledge of how to access the Documents and Letters MG template. Perform the following steps to access the Controlled Substance Agreement:

  1. Click on Controlled Substance link
  2. Click the Patient Signed Agreement check box.
  3. Click the Contract Reviewed check box. (Date will auto-populate on HPI)
  4. Select the Date Contract was Reviewed.
  5. Document any other restrictions or considerations in the space provided.
  6. Click Save & Close  
  7. Controlled Substance Agreement Generates
  8. Information now appears in the Reason for visit section.

Urine Drug Screen (UDS)

 

To order a (UDS) continue and open *Lab Master MG template. Lab code can be added to lab panel                                              

  • Pain Management Profile (13 Drugs) 763824
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