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Please update chief complaint above!!!
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Subjective
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Substance Abuse
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Primary substance of abuse
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Use onset
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Use duration
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Frequency
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Amount
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Last use
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Other substance of abuse
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Frequency
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Amount
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Last use
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Other substance of abuse
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Frequency
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Amount
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Last use
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Taken buprenorphine before?
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Obtained buprenorphine from
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Periods of abstinence
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Longest
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Methods/treatments used
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Current Pain Management
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Today's pain
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Average pain without rx
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Average pain with rx
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Analgesia
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ADLs
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Adverse SE
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Aberrant Behaviors
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Exacerbating
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Relieving
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Risk of Harm
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SI or HI?
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Plan
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Means
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Safety Plan
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Describe safety plan
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Psychiatric History
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Psychiatric history
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Diagnosis
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Historical medication trials
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Current medications
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Medical History
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Medical history
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Diagnosis
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Current medications
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Surgical history
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Seizure history
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Allergies
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Objective
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Vitals
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P:
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BP:
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RR:
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Temp:
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COWS and/or CIWA Scale
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PMP Results Consistent with hx
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UDS Results
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Labs reviewed
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Exam Findings
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Physical Exam
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General Appearance
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Ambulation
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HEENT
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Lung
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Cardiovascular
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Abdomen
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Neuro
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Changes in station
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Changes in motor strength
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Mental Status Exam
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All exam findings WNL
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Mood
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Speech
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Affect
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Thought Process
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Thought Content
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Insight/Judgment
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Assessment
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Assessment
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Plan
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Plan
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Justification for Program Recommendation
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Justification for program recommendation
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Recommended Phase of Treatment
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Recommended phase of treatment
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Medication Consent and Patient Safety
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Medication Consent and Patient Safety
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