How to Do a Drug Assessment

A drug assessment is a clinical evaluation of a patient's drug use upon entering a hospital or rehab facility. An assessment is given prior to treatment, which gives the medical staff the necessary information to proceed in the proper care and recovery of the patient. When a patient enters drug treatment, the staff assumes that she wants to get off drugs. Even so, not everyone entering rehab suffers from drug use in quite the same manner, meaning that the motivation to change is different for each person. Only a drug evaluation can reveal the patient's physical, emotional, and medicinal needs.

Instructions

• 1

  Obtain general personal information. Get his name, address, phone number, social security number, and socioeconomic background; also, get an emergency contact number. This information is needed to start his file and to contact him or a family member when necessary.

• 2

  Ask the patient what brought her into treatment. Get her to recall the event, feeling, or mood that caused her to seek professional help. The ingestion of bad drugs, a friend or relative's death, and/or loneliness might trigger a need to seek help and to get "clean."

• 3

  Ask him about his family. Record if the patient's family members took drugs and what type. Also, if he's married, find out if his spouse takes drugs. Lastly, inquire about his finances, since money tends to go towards drug use rather than family necessities. Get as much information about the effect of drugs on his family life.

• 4

  Inquire about her medical history. During the assessment ask the patient if she has any medical problems and whether she's on any medication(s). Document all responses and any doctor prescribed medications, past or present.

• 5

  Ask the patient about his educational background. Note if he finished high school or got his GED, or if he went to college. Don't assume that he's a high school drop out; although, using drugs during the teens years often interferes with the completion of high school.

• 6

  Note any psychological and/or behavioral problems. Document her verbal responses along with observable behaviors. Record if she is aggressive or passive during the interview. If she's belligerent, you may need to alert security so that her behavior doesn't escalate. Also, note whether the patient is scratching, irritable, agitated, or lethargic, which might signal recent drug use or withdrawal symptoms.

• 7

  Talk to the patient about his history of drug use. Ask when he took drugs for the first time and under what circumstances. Obtain information about drug or alcohol use with school friends. The first experience with drugs is often with a friend.

• 8

  Ask the patient how drugs affect her social life. You want to know if there is a support system other than relatives. Drugs do destroy friendships causing social isolation, which fosters an intense dependence on drugs. So find out if she's maintained friends that she can depend on in times of need.

• 9

  Get information about his work life, since drug use affects job performance, especially as he grows more preoccupied with getting and taking drugs. Ask if he's grown more aggressive at work with his boss and/or coworkers, or spent time in jail due to workplace incidents.

• 10

  Talk to the patient about past or present legal problems in regard to drug use, such as arrest, driving while intoxicated (DWI), child neglect, robbery, and/or aggressive attacks.