For every prescription, over-the-counter product, supplement, injection, or as-needed medication, record the name exactly as printed, dose on the label, how it is actually taken, prescriber, pharmacy, reason given for use, last dose, and any missed doses. Include allergies and past reactions separately. If the person takes something differently from the label, document both versions without trying to correct the discrepancy yourself.
Also list previous mental-health or substance-use treatment, emergency visits, hospital stays, and periods when symptoms improved or worsened. Record diagnoses only as prior clinicians described them, with the source and approximate date. Note previous medication problems and reasons treatment stopped, such as side effects, cost, loss of contact, or the person’s decision. Never guess which medication a facility will provide. SAMHSA quality guidance supports asking whether medications are available when clinically appropriate, but that principle does not establish any particular medication or prescribing practice at Living Longer Recovery.
- Current medication name, label dose, actual use, prescriber, pharmacy, and last dose
- Medication allergies, adverse reactions, and relevant nonprescription products
- Previous treatment locations and dates, with available discharge papers or summaries • Emergency and hospital history, including approximate dates