Addiction Research, Education and Training | IRETA



a. Client Sobriety Checklist – The nurse will use the following guidelines as a documentation tool for use in the assessment of clients who may be under the influence of drugs or alcohol.

1. The client’s name, their counselor’s name and the date should be filled in at the top of the form.

2. The nurse evaluating the client will follow the checklist, documenting the findings directly on the form.

3. Vital signs will be documented as well as pupil dilation and reaction.

4. Any sedation or somnolence should be documented.  This may be assessed by requesting the client to sit for at least twenty (20) minutes.

5. Speech quality and ability to maintain balance when walking/standing should also be documented.

6. In addition, the results of the following neurological tests should be documented:

|ORIENTATION |ROMBERG TEST |SOBRIETY TEST |MOTOR COORDINATION |

| | | | |

| | | |Ask client to stand with arms |

|Test client’s awareness by asking |Ask client to stand with his feet |Ask client to walk a straight |stretched outward and eyes closed.|

|client: |together (touching each other), |line heel-to-tow. Normal is the |Instruct client to use index |

|Name |arms resting at sides, first with |ability to do so. Deviation is if|finger to alternately touch nose |

|Place where he/she is |eyes open and then with eyes |unable to do so without stepping |rapidly. Normal is the ability to |

|Today’s date |closed. Normal is a slight swaying,|to a wider base. |do this. Deviation is missing nose|

| |but with foot stance maintained. | |many times or arms unable to |

| |Deviation is if client needs to | |maintain testing position. |

| |move foot stance to maintain | | |

| |balance. Remain close at hand in | | |

| |case client begins to sway or fall.| | |

7. In addition, the BAL reading should be included as well.

8. If the client is under the influence and presents a risk to his own or other’s safety, the client will be asked to let staff contact someone to take them home.  This information should be documented as well in the client’s file.

9. If the client insists on driving himself home, he will be informed that the clinic will notify the sheriff’s department with their car make, license number and the circumstances involved.  This would also be documented. 

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