Consumer Name: Incident Date: UIRMS #: Was the consumer diagnosed with, or known to have, a substance use disorder? Please explain. Describe any treatment the consumer received by your agency for the substance use disorder. If treatment was provided elsewhere, what were the arrangements for coordinating care? Was the consumer regularly attending the program and following the plan of treatment for mental health and/or substance use? If not, what efforts were made to reach out to the consumer and how successful were they? Describe the use of Urine Drug Screens (UDS) or the Prescription Monitoring Program (PMP) upon admission or during any other part of consumer’s treatment. Please explain what was done. What were the results of consumer’s most recent Urine Drug Screens (UDS)? If positive, what was/were the substance(s)? What interventions were made if the outcome was positive? If the overdose was verified, describe the circumstances and identify the substances used in the overdose. Were any of the substances prescribed? What immediate action was What was the outcome? Could the overdose have been intentional and a suicide attempt? If so, please submit Appendix 4. Describe any factors or circumstances that could have recently increased the consumer’s overdose risk, such as a recent detox or a period of enforced abstinence from opioid drug use, or recent increase in drug use, or a medical condition that could have contributed to drug toxicity. Was there a known history of overdose prior to admission or during the current treatment episode? Describe substances used and dates of the overdose(s). What efforts were made to reconnect the consumer with treatment following the overdose and were they successful? What education has the consumer received on the of overdose? Has the consumer received a naloxone (Narcan) kit to use in an opioid overdose? How was the consumer/significant other instructed on how to use it and also how to obtain further treatment following an overdose?
Consumer Name: Incident Date: UIRMS #: Was the consumer diagnosed with, or known to have, a substance use disorder? Please explain. Describe any treatment the consumer received by your agency for the substance use disorder. If treatment was provided elsewhere, what were the arrangements for coordinating care? Was the consumer regularly attending the program and following the plan of treatment for mental health and/or substance use? If not, what efforts were made to reach out to the consumer and how successful were they? Describe the use of Urine Drug Screens (UDS) or the Prescription Monitoring Program (PMP) upon admission or during any other part of consumer’s treatment. Please explain what was done. What were the results of consumer’s most recent Urine Drug Screens (UDS)? If positive, what was/were the substance(s)? What interventions were made if the outcome was positive? If the overdose was verified, describe the circumstances and identify the substances used in the overdose. Were any of the substances prescribed? What immediate action was What was the outcome? Could the overdose have been intentional and a suicide attempt? If so, please submit Appendix 4. Describe any factors or circumstances that could have recently increased the consumer’s overdose risk, such as a recent detox or a period of enforced abstinence from opioid drug use, or recent increase in drug use, or a medical condition that could have contributed to drug toxicity. Was there a known history of overdose prior to admission or during the current treatment episode? Describe substances used and dates of the overdose(s). What efforts were made to reconnect the consumer with treatment following the overdose and were they successful? What education has the consumer received on the of overdose? Has the consumer received a naloxone (Narcan) kit to use in an opioid overdose? How was the consumer/significant other instructed on how to use it and also how to obtain further treatment following an overdose?
Appendix2a_electronic.docx