Table.2.

Characteristics of non-medical non-tobacco substance use documentation from electronic health record chart review of current cigarette smokers (N=176)

	N (%)
Non-tobacco substance use (SU) was documented in health record
Yes	121/176 (69%)
No	55/176 (31%)
Type of non-tobacco SU documenteda
Alcohol	116/176 (66%)
Patient endorsed use	76/176 (43%)
Patient denied use	36/176 (20%)
Unknown/not listed in chart	4/176 (2%)
Cannabis	5/176 (3%)
Patient endorsed	4/176 (2%)
Patient denied or unknown	1/176 (< 1%)
Opioids	4/176 (2%)
Patient endorsed	2/176 (1%)
Patient denied	1/176 (< 1%)
Unknown/not listed	1/176 (< 1%)
Other (e.g., “other drugs,” “illicit,” “drug abuse,” “IVDU”)b	43/176 (24%)
Patient endorsed use	4/176 (2%)
Patient denied use	33/43 (77%)
Unknown/not listed	6/176 (3%)
Number of non-tobacco substances documented
1	74/176 (42%)
2	42/176 (24%)
3 or 4	5/176 (3%)
Among those with SU documented	121/176 (69%)
Who documented SU
Physician	102/121 (84%)
Physician Assistant/Nurse Practitioner	12/121 (10%)
Nurse	5/121 (4%)
Other (i.e., social worker, dietician)	2/121 (2%)
Note type where SU documented
Consultation note	52/121 (43%)
Progress note	68/121 (56%)
Inpatient/hospitalist	1/121 (1%)
Note section where SU documented
Social history	102/121 (84%)
Past medical history	6/121 (5%)
Habits/risk factors	7/121 (6%)
Interval history	2/121 (2%)
Psychiatric/behavioral health	1/121 (1%)
History of present illness	1/121 (1%)
Medical problems	2/121 (2%)
Follow-up plan documented for SU	4/121 (3%)
Where documented
Plan section	3/121 (75%)
Attending addendum	1/121 (25%)

^aProviders could document multiple substances of use for a single patient; thus, SU types are not mutually exclusive categories

^bProviders documented the following other substance use: “drug use, illicits”; “illicit substances”; “illic- its”; “IVDA/IVDU”; “drug abuse”; “drug use”; “drug use, IV drug use”; “drugs”; “other drugs”; “past narcotic”; “recreational drugs”; “substance use history”