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