Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for OUD
Medication review for OUD treatment
Follow-up for OUD treatment and monitoring
Chief Complaint:
pen_spark
(Optional)
Patient’s own words about their struggles with opioid use
(cravings,
relapses).
History of Present Illness:
Current opioid use patterns (type, frequency, route of administration).
History of past attempts to quit or reduce opioid use.
Consequences of opioid use on physical and mental health,
relationships,
work, and legal situations.
Presence of withdrawal symptoms (if applicable).
Past Medical History:
Medical conditions related to opioid use (e.g., constipation,
respiratory depression, infections).
Mental health conditions (e.g., depression, anxiety, PTSD) that may
be co-occurring with OUD.
Pain history (if chronic pain is a contributing factor).
Social History:
Living situation and social support system (positive and negative
influences on opioid use).
Occupational history (work-related stressors or injuries).
Legal history (past arrests or convictions related to substance use).
Family History:
Family history of substance use disorders.
Mental Status Exam:
Brief assessment of mood, affect, thought processes, and presence of
active suicidal ideation.
Substance Use Assessment Tools:
(Consider using validated tools to assess severity of OUD)
DSM-5 criteria for OUD
Addiction Severity Index (ASI)
Short screener tools (e.g., ASSIST, AUDIT-C)
Assessment:
Opioid Use Disorder (OUD): Diagnosed based on DSM-5 criteria considering
history of opioid use, tolerance, withdrawal symptoms, and impaired
functioning due to opioid use.
Severity of OUD: Mild, moderate, or severe based on DSM-5 criteria.
Co-occurring mental health conditions: Identify any co-occurring
conditions like depression or anxiety.
Risk factors for relapse: Assess factors that may increase risk of
relapse (e.g., social support, access to triggers, mental health symptoms).
Plan:
Treatment options: Discuss options based on individual needs and
severity of OUD. May include:
Medication-assisted treatment (MAT):
Methadone
Buprenorphine (Suboxone, Subutex)
Naltrexone (blocks the effects of opioids)
Behavioral therapy (individual and/or group counseling)
Peer support groups (e.g., Narcotics Anonymous)
Pain management strategies (if chronic pain is a factor)
Addressing co-occurring mental health conditions
Referral to specialist: Consider referral to an addiction specialist
or pain management specialist if needed.
Harm reduction strategies: Discuss strategies to minimize risks
associated with opioid use (e.g., needle exchange programs, Naloxone
prescription).
Follow-up: Schedule regular follow-up appointments to monitor
progress, adjust treatment as needed, and provide ongoing support.
Patient education: Educate the patient about OUD, treatment options,
and the importance of medication adherence and participation in therapy.
Prognosis:
OUD is a chronic, relapsing condition. Early intervention and
comprehensive treatment can improve outcomes. Prognosis depends on
severity of OUD, co-occurring conditions, and patient’s commitment to recovery.
Additional Notes:
Document any safety concerns (e.g., suicidal ideation, active
substance use).
Document patient’s willingness to engage in treatment.
Consider involving family members or significant others in the
treatment plan when appropriate.
Disclaimer: This template is a guide and may need to be adapted
depending on the specific patient and their individual needs. It is
recommended to consult with addiction medicine specialists for
diagnosis and treatment planning.