History of Present Illness (HPI) Assessment and Plan Template
Templates for induction and follow-up appointments for medication assisted treatment (MAT)
in opioid use disorder (OUD). Consider saving this document electronically to quickly cut and
paste sections into your EHR.
Underlined sections are options, choose the answer that represents the current patient
experience.
History of the Present Illness Template
Patient is a x yrs. old, (fe)male who presents today for MAT, patient was recently in
hospital on a hold. Patient started on opioids after surgery x years ago. Took mostly
prescription medications. Then became dependent on opioids and borrowed/stole
medications from family and/or friends. Occasionally purchased prescription opioids on
the street. Has been using opioids for x years. Occasional heroin use.
Patient has used opioids for 5 years after ACL tear. Patient stated (s)he uses around
150mg of oxy per day. Patient admits to using heroin X 2 and once is it was mixed with
meth. Here with his father.
Desires to get off opioids. Has had several friends commit suicide in the past month and
really wants to get help. Has started seeing counselor at __________ last month.
Patient applied for Medication Assisted Treatment (MAT) and the [clinic] MAT Team
reviewed and approved patient for MAT. Patient has agreed to participate in all aspects
of treatment plan including follow-up appointments, counseling, group visits, urine drug
testing, and other requirements as noted in the treatment protocol and patient
agreement.
Last opioids x hours ago of long-acting / short acting opioid.
Today, patient feels pretty lousy today. Anxious, slight abdominal pain.
Patient has good / limited social supports with family, neighbors, and friends.
Specifically, patient will have support from____________
Opioid Use Disorder Criteria. Mark all that apply to this patient. Include in HPI.
Opioids are often taken in larger amounts or over a longer period of time than
intended.
There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
A great deal of time is spent in activities necessary to obtain the opioid, use the
opioid, or recover from its effects.
Craving, or a strong desire to use opioids.
Recurrent opioid use resulting in failure to fulfill major role obligations at work, school
or home.
Continued opioid use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of opioids.
Important social, occupational or recreational activities are given up or reduced
because of opioid use.
Recurrent opioid use in situations in which it is physically hazardous
Continued use despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by opioids.
*Tolerance, as defined by either of the following:
o a need for markedly increased amounts of opioids to achieve intoxication or
desired effect
o markedly diminished effect with continued use of the same amount of an
opioid
*Withdrawal, as manifested by either of the following: the characteristic opioid
withdrawal syndrome, the same (or a closely related) substance are taken to relieve
or avoid withdrawal symptoms
MAT Induction Assessment and Plan Template
Opioid use disorder. MAT Induction. Patient desires medication assisted treatment with
buprenorphine/naloxone. Discussed long-term treatment. Understands the benefits and
risks. Patient has developed treatment goals and life goals.
Stopped opioids yesterday for short-acting opioids, two days ago for long-acting.
Patient applied for Medication Assisted Treatment (MAT) and the [your practice name]
MAT Team reviewed and approved patient for MAT. Patient has agreed to participate in
all aspects of treatment plan including follow-up appointments, counseling, group visits,
urine drug testing, and other requirements as noted in the treatment protocol and
patient agreement. Patient agreement/consent signed.
Physical exam completed. See PE, pertinent findings include:
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o Labs reviewed: HIV, HBV, HCV, LFTs, Urine toxicology, and pregnancy test.
o No opioids for xx hours. In ______ withdrawal. COWS = __________
Begin buprenorphine induction with 2mg/0.5mg or 4mg/1mg SL suboxone.
Patient picked up prescription at the pharmacy and brought with them to this
appointment. Patient instructed in proper use of medication and long-term treatment per
practice protocol. Observed 1st dose in office.
1 hour re-check; doing much better. Less anxious and shaky. Not 100% but overall
much better. Discussed treatment goals for the future, long-term nature of treatment,
and how the patient will utilize the other components of treatment; counseling, group
visits, drug testing, and family and community support.
Second dose of suboxone 4mg/1mg given.
2 hour re-check; doing much better. Near baseline. COWS=_________
Continue counseling and education about medication assisted treatment. MAT is most
effective when combined with counseling and expanding family and social supports.
Provided patient with a handout about opioid use disorder and medication assisted
treatment, reviewed components of this handout, treatment and potential side-effects,
how to access professional and community support systems, contingency plans for
cravings and/or withdrawal symptoms.
Enroll in Opisafe, online management for MAT. Opisafe will provide weekly and bi-
weekly check on withdrawal (SOWS), depression (PHQ2/9), Generalized Anxiety,
sleep, and medication side effects. We will follow these clinically and patient can check
in with us, and we will check in with the patient if there are any important changes.
Patient’s preferred email is___________.
Naloxone education and training provided to patient to decrease overdose risk.
Plan for patient to use total dose of 12mg/3mg per day. 8mg in am and 4mg pm for
next few days. We will check in with patient tomorrow and in 3 days by phone. See
patient back in clinic in 1 week for follow-up and prescription refills. Continue full MAT
program through Southeast Health Group with counseling, support, random UAs.
Precautions discussed. Call or return if worse symptoms, withdrawal, or cravings.
Patient in office for 2.5 hours. Greater than 60 minutes/50% of visit spent in medical
care, education, and counseling as noted above. Tolerated MAT induction well. Much
improved.
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Other Potential Components of Induction Note
Plan daily dose of 12mg/3mg. Given his/her prior dose of opioid use, may need higher
dose. Will follow closely over next few days.
Patients not currently dependent on opioids but high risk for relapse and meet other
criteria for OUD (has been in jail or detox and has gone through withdrawal)
Patient desires MAT for OUD. Patient meets criteria for recurrent opioid use disorder.
Not currently dependent, but very high risk for relapse.
Follow-Up Appointment
Opioid use disorder. Patient desires medication assisted treatment with
buprenorphine/naloxone. Understands the benefits and risks. Here today for follow-up
appointment after suboxone induction on __/__/20__.
Reviewed Opisafe patient reported measures. Depression score _________ /
GAD/Anxiety_______ / Quality of Life__________ / Pain/function__________
Now in stabilization / maintenance phase of treatment.
Today, no signs of withdrawal. COWS = ________
Patient reports side effects of: none, constipation, nausea, headaches
Cravings: none / few / often
Current dose: ________
Last fill: ________
Pill/film count: ________
PDMP/OpiSafe Check: ________
Last UDT date and results: ________
Doing well / very well with treatment. Has gotten enrolled in counseling and I stressed
the critical importance of counseling and behavioral health care in addition to MAT.
Patient voiced understanding and willingness to participate fully in treatment. No
evidence of drug diversion. No relapse / relapse with continued interest in continuing
buprenorphine MAT program.
Patient instructed in proper use of medication and long-term treatment per practice
protocol.
Naloxone education and training provided to patient to decrease overdose risk.
We will check in with him weekly. Precautions discussed. Call or return if worse
symptoms, withdrawal, or cravings. Enrolled in Opisafe, online management for MAT.
Opisafe will provide weekly and bi-weekly check on withdrawal (SOWS), depression
(PHQ2/9), Generalized Anxiety, sleep, and medication side effects.
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Discussed potential side effects and their management. Osmotic stool softener for
constipation. (Miralax)
Continue suboxone SL total daily dose of 16mg/4mg, divided dose, 8mg/2mg am and
8mg/2mg evening. Scripts written.
Appointment in 3-4 weeks for recheck and refills. Continue full MAT program through
the practice with counseling, support, random UAs, etc.
UA today for buprenorphine and opioid drugs of abuse.
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Suboxone Script Writing
Induction day script
Suboxone 4mg/1mg
Sig. 1-3 daily as directed by provider
#30. No refill
Maintenance
Suboxone 4mg/1mg 8mg/2mg 12mg/3mg
Sig.
#30
Suboxone comes in boxes of 30 and if you write for fewer, the pharmacist must waste the
remainder and cannot relabel or reuse.
For permission to use outside of IT MATTTRs Colorado, please contact [email protected]
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