CC-UC-01200 - Community Health Centre: Basic Flow - Substance Use Assessment

Actors

• Client/Client caregiver
• Medical administrator
• Registered Nurse (RN)
• Medical Doctor (MD)/Nurse Practitioner (NP)

Pre-conditions

• The client is covered under provincial/territorial health care insurance.
• The client is on the clinic roster.
• Intake and registration has been completed.
• The client is in active addiction.
• The substance use assessment is initiated by the client.
• RN records the client's allergies and current medication(s).

Step	Description	Data elements collected	Result
1	RN reviews and records the results and rationale for the substance use assessment.	Alcohol use status Tobacco use status Vape use status Other substance use status Pack years Standard drinks Substance product type Substance source Substance route of administration Substance quantity value Substance quantity unit of measure Substance consumption frequency Substance use period Substance use duration Substance use duration Substance use duration unit of measure Substance use observation status Date of observation	The results and rationale for the substance use assessment are recorded in the client's medical record.
2	MD/NP validates the health concern described by the client and reviews the results of the substance use assessment.	Health concern Substance use assessment data elements Alcohol use status Tobacco use status Vape use status Other substance use status Pack years Standard drinks Substance product type Substance source Substance route of administration Substance quantity value Substance quantity unit of measure Substance consumption frequency Substance use period Substance use duration Substance use duration Substance use duration unit of measure Substance use observation status Date of observation	The client's health concern is validated, the substance use assessment results are reviewed, and the client's medical record is updated.
3	MD/NP recommends a care plan that may include but not be limited to: Referral to the Emergency department Referral to other health car providers (psych, social worker addiction program etc.) Prescription medication(s) Educational resources	Not applicable	A care plan is recommended and the details are recorded in the client's medical record.
4	MD/NP schedules a follow-up appointment.	Appointment Services by Appointment Only Flag Appointment Service Category Appointment Service Type Appointment Creation Date and Time Appointment Requested Range Appointment Priority Appointment Expected Duration Appointment Reason Appointment Instructions Appointment Confirmation Status Appointment Attendance Requirement Appointment Participation Period Appointment Period Appointment Specialty Appointment Type Appointment Cancellation Date and Time Appointment Rescheduled Date and Time Appointment Cancellation Reason Appointment Rescheduled Flag	Follow-up appointment is scheduled and recorded in the client's medical record.
5	Use case ends	Not applicable	Not applicable

Post-conditions

• Substance use assessment is completed recorded/updated.
• A care plan is recommended.
• A Follow-up appointment is scheduled.
• The client medical record is updated.

Back to use case category

Contact us

If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.

connectedcare@cihi.ca