Opinion ID: 4387846
Heading Depth: 2
Heading Rank: 3

Heading: Substance Abuse Withdrawal Flowsheet

Text: As a part of her intake, Kohl additionally completed a Substance Abuse Withdrawal Flowsheet. At the top of the Flowsheet, she handwrote the time as 5:06 PM. The next part of the Flowsheet stated, “Observation for (mark all that apply)” with the options of “ETOH,” “Benzodiazepine,” “Opioid,” and “Mixed/Unknown.” Substance Abuse Withdrawal Flowsheet, R. 98-3, Page ID # 609. Kohl did not mark any of these options. The next part of the Flowsheet stated, “Tool used,” with the options of “CIWA-Ar,” “BWS-C,” “COWS,” and “CIWA-Ar.” Id. Kohl checked the first “CIWA-Ar.” Id. In the next part of the Flowsheet, Kohl documented Cross’s temperature, pulse, respiration, blood pressure, and orientation, among other things. Cross’s vital signs fell within the normal ranges included on the Flowsheet, and Kohl wrote “mild,” selecting from the range of “severe” to “mild,” for his symptoms. Id. Under “Provider Notified” and “New Orders Rec’d,” Kohl marked “Y.” Id. Under “Observe . . . Hours,” Kohl wrote “8.” Id. Ultimately, Kohl assigned Cross a base severity score of “0.” Id.