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Follow up visit (no input)
|
Length of Time on Buprenorphine Product
|
|
|
|
|
Subutex use
|
Buprenorphine Dosing
|
|
Generic Suboxone use
|
Generic Suboxone Dosing
|
|
Suboxone use
|
Suboxone Dosing
|
|
Zubsolv use
|
Zubsolv Dosing
|
|
Bunavail use
|
Bunavail Dosing
|
|
|
|
|
Narcan prescribed
• • •
|
|
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Is pregnant
|
Number of weeks pregnant
|
|
|
|
|
Counseling since last visit?
|
Date of Last Counseling:
|
|
Counselor:
|
|
|
Case management since last visit?
|
Date of Last Case Management:
|
|
|
|
|
Strike one
|
Reason and date for strike one
|
|
Strike two
|
Reason and date for strike two
|
|
Strike three
|
Reason and date for strike three
|
|
|
|
|
SUBJECTIVE
|
|
|
Contraception Used
• • •
|
|
|
Maintaining Sobriety?
|
Sobriety explanation:
|
|
Taking medication as prescribed?
|
Medication explanation:
|
|
Continues to benefit from treatment?
|
No Benefit explanation:
|
|
Ready for taper?
|
|
|
Other concerns?
|
Other concerns explanation:
|
|
|
|
|
OBJECTIVE
|
|
|
|
|
|
Urine Toxicology Screen Performed
|
Last Urine Drug Screen (Date / / )
|
|
Drugs Present on Toxicology Screen
• • •
|
|
|
Valid Urine Toxicology Screen?
|
Toxicology screen is not valid because:
|
|
Specimen read by M.D.?
|
|
|
Specimen sent to lab for further validation?
|
Last date sent to lab
|
|
Is the urine specimen observed?
|
|
|
Additional Exam Findings of Note
|
|
|
|
|
|
ASSESSMENT
|
|
|
Diagnosis
• • •
|
|
|
Pill count correct?
|
Explanation:
|
|
Appropriate Dosage
|
Explanation:
|
|
Making Progress Towards Treatment Goals
|
Explanation:
|
|
TNCSMD Checked and OK
|
Explanation:
|
|
Urine Drug Screen
|
Explanation:
|
|
Next Visit
|
Explanation:
|
|
Counseling
|
Explanation:
|
|
Chronic maintenance justified?
|
Explanation:
|
|
|
|
|
Dimension 1: Intox / Withdraw Risk
|
Intoxication / Withdrawal risk explanation
|
|
Dimension 2: Biomedical conditions
|
Biomedical conditions
|
|
Dimension 3: Emotion/Behav/Cog conditions
|
Emotional / behavioral / cognitive explanation
|
|
Dimension 4: ready to taper?
|
Readiness for change explanation
|
|
Dimension 5: risk of relapse?
|
Explanation of continued risk potential.
|
|
Dimension 6: healthy living environment?
|
Living environment explanation
|
|
Additional Notes:
|
|
|
Counseling Topics
• • •
|
Additional Explanation of Counseling
|
|
Arranging Care
• • •
|
Additional Explanation of Arranging Care
|
|
PLAN
|
|
|
|
|
|
Plan
• • •
|
|
|
Medication Refill (YES) or (NO) refill?
|
|
|
Subutex use
|
Buprenorphine Dosing
|
|
Generic Suboxone use
|
Generic Suboxone Dosing
|
|
Suboxone use
|
Suboxone Dosing
|
|
Zubsolv use
|
Zubsolv Dosing
|
|
Bunavail use
|
Bunavail Dosing
|
|
Number of Units Prescribed
|
|
|
|
|
|
Return visit in:
|
|
|
Set modify date?
|
|
|
|
|
|
Time spent counseling / Total visit time
/
|
|
