Template Control Page Substance Misuse Newham Template Guide Title Substance Misuse Newham Author CEG Status Active Date September 2015 DOCUMENT MANAGEMENT REVISION HISTORY Version Date Summary of Changes AUTHORISATION Reviewed by Approved by Appendices sub-templates, protocols and information screens used by this template EMIS Web Library Items Lifestyle intervention CEG 1.0 Ethnicity (with visibility rule) CEG Protocols 1
Substance Misuse Newham Template Guide The template includes coded data entry for all the quality indicators for xxxxxa required by the GP GMS contract. These are marked with *. We have included a number of other items which monitor good practice. Enhanced service indicators will be indicated with ** on clinical template. We have deliberately not included the diagnosis code in the template, in case including it encourages multiple entries over time. MAIN PAGE Prompt Code What does this prompt mean? EMISWeb Consultation Section Reviews For enhanced service payment, the **Drug addiction therapy code is needed for every consultation for substance misuse. This should be at least once a month. It now comes ticked by default so you don t have to do it. **Drug addiction 8B23 Checked by default therapy Next review Diary entry Screen before and after starting prescribing and usually 3 monthly. **Screening test Urine sample sent to Lab (4146) Drugs of abuse screening test ( 44q9) No drug found in urine (46Q1) Saliva sample sent to lab (4148) Allow text Test request Last coded entry of drug urine level 46Q Last entry of code Include child codes Reviews: 1 Each patient will have a GP treatment agreed in conjunction with the patients keyworker on start of the treatment episode and coded within one month 2 The treatment and care plan review needs to be done quarterly in conjunction with the keyworker 3 All new patients engaged in OST for less that six months will be offered a comprehensive review with the prescribing GP and the keyworker 2
Review of goals 8CMX Clinical code Drug therapy Type of drug dependence Type of drug dependence Intravenous drug user Uses needle and syringe exchange scheme Referrals Referral for further care Health Education Advice Maintenance therapy (8BE) Detoxification dependence drug (8BA9) Use the alcohol screening section of the Lifestyle Intervention page (and Full Alcohol AUDIT page if necessary) to record alcohol consumption and AUDIT-C Opioid type drug dependence (E241) H/O crack cocaine misuse (1T6) Cocaine type drug dependence (E242) Cannabis type drug dependence (E243) Amphetamine or other psychostimulant dependence (E244) Drug dependence (E24z) Allow text 13c1 History 1V3N Clinical code Additional Referral to physician (8H4) Psychiatric referral (8H49) Referral to Services Additional Safer sex advice 679K Health education sexual health Additional Drug use advice 679A Health ed. drugs of addiction Additional Contracep. Advice 6777 Contraception counseling Additional Other Ask if children live at parents residence Ask about safe storage of medication in the home Patient advised to inform DVLA Housing difficulty 8CA9 Homeless family (13D1) Homeless single person (13D2) 3
migrant (13D4) Lives in squat (13D6) Sofa surfer person of no fixed abode (13D7) Occ. Status? Unemployed (13J7) In employment (13JV) Sickness benefit (13O1) Retired (13J5) Student (133A) Legal problem Imprisonment record (13H9) Charged with crime (13HM0) Court case pending (13HM4) On probation (13HR) Asylum seeker (13ZN) Illegal immigrant (13D4) Failed asylum seeker (13Zd) Allow text Review the pages on the left hand side Examination Sites and skin O/E Injection sites abnormal (2F16) O/E Injection sites normal (2F18) O/E general skin exam. NOS (2F1Z) Examination Blood pressure Height 229 Weight 22A Body Mass index Key Working Agencies Newham Substance Misuse Service 020 7511 3740 Hepatitis and HIV Screening Page Immunisation advice Imms advice 6797 Health ed. immunisation Additional Hepatitis A Hep A Status Hepatitis A immune (2J21) Hepatitis A non immune (2J22) 4
Hep A vaccination Hepatitis B Hepatitis B screening declined Hep B status Hep B vaccination Due for Hep B screening test Due for 1 st Hep B vaccination Hepatitis C Hepatitis C screening declined Hep C status HIV HIV screening declined HIV Status 1 st Hepatitis A vaccination (65FA) 2 nd Hepatitis A vaccination (65FB) 3 rd Hepatitis A vaccination (65FC) Booster Hepatitis A vaccine. (65FD) Procedure 813u Allow text 4JR1 65F1 Viral (serum) hepatitis B (A703) Hepatitis B immune (43B2) Hepatitis B non immune (43B6) 1 st hepatitis b vaccination (65F1) 2 nd hepatitis B vaccination (65F2) 3 rd hepatitis B vaccination (65F3) 4 th hepatitis b vaccination (65F6) Boost hepatitis B vaccination (65F4) Diary entry Diary entry Procedure 8I3v Allow text Hepatitis C antibody test positive (43X3) Hepatitis C antibody test negative (43X4) 8I3p Allow text HIV Negative (43C2-1) HIV Positive (43C3-1) Full Alcohol AUDIT AUDIT Question Q1. How often do you have a drink containing alcohol? or less 1 pts 2 to 4 times a month 2 to 3 times a week 5
4 or more times a week 4 pts Q2. How many units of alcohol do you drink on a typical day when you are drinking? 1 or 2 3 or 4 1 pts 5 or 6 7 to 9 10 or more 4 pts Q3. How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Q4. How often during the last year have you found that you were not able to stop drinking once you had started? Q5. How often during the last year have you failed to do what was normally expected from you because of your drinking? Q6. How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Q7. How often during the last year have you had a feeling of guilt or remorse after drinking? Q8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? 6
Q9. Have you or somebody else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year 4 pts Q10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, during the last year 4 pts Scoring: 0-7 Lower risk 8-15 Increasing risk 16-19 Higher risk 20+ Possible dependence Resources Resources for clinicians Click here for Nice Hyperlink guidelines Click here for Hyperlink National Treatment Agency website http://www.nice.org.uk/guidance/cg52 http://www.nta.nhs.uk/guidance.aspx 7