Unfortunately, in our society, substance dependence is rampant. There is alcohol dependence and illegal drug dependence. There is also dependence to opioid pain medications. The documentation of the disorders is critical to better describe the patient’s case and to seek adequate reimbursement for the utilized resources. Whenever there is substance dependence it is necessary to specify if there are intoxication, withdrawal or psychiatric conditions associated to it such as mood or anxiety disorders. For example, it is very different to treat an alcoholic who only needs counseling than to treat a case of delirium tremens in the ICU.

Marco A. Ramos MD, CCDS

In order to quote from this article please use the following:

Marco A. Ramos, “Clinical Documentation Improvement Series #6. Substance Dependance and Associated Conditions,” SMO Blog (blog), August 25, 2018, https://steemit.com/health/@secondmedicalop/clinical-documentation-improvement-series-6-substance-dependence-and-associated-conditions

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies

- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.

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