A useful description is chronological, specific where possible, and honest about uncertainty. The governed core guide to heroin rehab in California can help you frame the topic, while Living Longer Recovery admissions guidance for call preparation, real‑ can help you prepare questions without treating a website as confirmation of admission or services.
Use a six-column note, whether on paper or in a phone: substance, form, amount, frequency, last use, and recent change. In the substance column, record the name the person uses for it. Under form, note observable details such as powder, pill, or unknown. For amount, copy the person’s own unit if it is meaningful to them, such as “one bag,” but do not convert it into a medical dose. Add “amount not verified” when appropriate.
Frequency should show the pattern rather than a vague label. “On four of the last seven days” conveys more than “often.” For last use, write the exact date and approximate time if known. If not, use a bounded statement such as “between 8 p.m. and midnight on March 10.” Under recent changes, note increases, decreases, return to use after a period without use, a new source, a different appearance, or the addition of another substance. Report facts without interpreting what they mean clinically.
- Create one timeline row for every substance or medication mentioned.
- Use exact dates and local times when known.
- Preserve the person’s units instead of estimating a dose conversion to mg dose examples, vary by source and product composition; professional assessment is needed to interpret them