Your note can be a table on paper or in your phone. Give it six columns: substance, form, amount if known, frequency, last use, and recent changes. Add separate rows for alcohol, prescribed medications, nonprescribed medications, cannabis products, stimulants, opioids, sedatives, or anything else used. Use the name you know, but identify uncertainty. For example: “powder sold as cocaine” is more precise than asserting that an untested powder was cocaine.
In the amount column, write the unit as well as the number: cans, ounces, tablets, milligrams shown on a prescription label, bags, lines, or an unknown amount. Avoid converting units unless you are confident. In the frequency column, distinguish “daily” from “three days this week,” and record whether use occurs once or several times during a day. For last use, include the date and approximate time. “Monday at about 8 p.m.” gives more context than “recently.” If you use again after making the note, update it before or during the call rather than hiding the change.
- Substance name, including uncertainty about identity or contents
- Form, such as beverage, tablet, powder, liquid, or another form
- Amount and unit, or “unknown” if you cannot estimate reliably at time of call likely currently varies is important to note accurately accurately accurately accurately accurately to