Crisis Intervention Note (Substance Use Disorder)

Date: [Date]

Time (start/stop or total): [Start time – Stop time / Total time]

Setting: [emergency department / urgent care / clinic / residential facility / community / field]

Mode of contact: [in-person / telehealth (video) / telephone]

Participants present: [Participants present and roles]

Interpreter: [No interpreter used / Interpreter used – language and modality]

(Use person-first, non-stigmatizing language throughout. Document events chronologically. Be explicit about uncertainty; if reliability is limited, document limitations and reassessment plan. For critical safety elements not assessed, write "Not assessed" with reason rather than omitting.)

Crisis Snapshot

• Chief concern: [Patient's primary concern in their own words] (If patient cannot provide, note source and reason)
• Trigger for today's crisis: [Precipitating event or trigger]
• Immediate risks identified: [overdose / withdrawal / suicidality / violence / medical instability / unknown] (Select all that apply)
• Actions taken prior to evaluation: [Pre-arrival actions such as naloxone given, EMS transport, bystander interventions]
• Status at first clinician contact: [intoxicated / withdrawing / stable / unclear]; [cooperative / agitated / somnolent / disoriented]
• Information sources and reliability: [patient / family / EMS / law enforcement / chart / PDMP] — reliability: [good / limited by intoxication / conflicting / collateral unavailable]

Crisis History of Present Illness

[Narrative summary describing time course (onset, escalation, peak, current status); substances involved with temporal relation to symptoms; last use time, amount, route, and co-ingestants if known; withdrawal warning signs; recent overdose or naloxone use; brief safety concerns; and immediate social drivers impacting safety or stabilization. Keep focused on crisis-relevant details.]

(If patient is intoxicated or otherwise unreliable, explicitly state limitations and plan for reassessment. Additional structured details below may be included when helpful for clarity:)

• Substances and timing: [Substance(s)], [last use], [amount], [route], [co-ingestants]
• Withdrawal concerns: [Current symptoms], [history of seizures or delirium], [prior treatment responses]
• Overdose concerns: [Recent overdose], [naloxone required], [polysubstance involvement]
• Safety flags: [Suicidal thoughts], [self-harm], [violence risk] — [present / absent / unknown] (Details in Safety & Risk Assessment)
• Social crisis drivers: [Housing], [environmental safety], [violence exposure], [loss of supports], [legal issues]

Pertinent Background

(Include only information relevant to the current crisis and disposition decisions. Document "Unknown" if not obtainable.)

• Substance use history: [Primary substances], [pattern and recent escalation], [prior treatment], [prior overdoses], [withdrawal complications], [MOUD history and response]
• Psychiatric history: [Relevant diagnoses], [prior suicide attempts or self-harm], [hospitalizations]
• Medical history (acuity-relevant): [Pregnancy status], [seizure disorder], [hepatic disease], [respiratory or cardiovascular conditions], [other conditions affecting acute management]
• Medications and allergies: [Current medications including MOUD, benzodiazepines, antipsychotics], [relevant allergies]
• Social factors impacting disposition: [Housing], [transportation], [caregiving responsibilities], [support system], [ability to obtain medications or attend follow-up]

Screening Tools

(Include only if standardized measures were administered. If none administered, note "No standardized screening tools administered this encounter.")

• [Tool name] — [Score] — [Clinical interpretation] — [Time]
• (If a tool could not be completed, document reason: e.g., "CIWA-Ar deferred due to intoxication")

Objective Findings

• Vital signs: [Time] — BP [value], HR [value], RR [value], Temp [value], SpO2 [value] (Include repeat vitals with times if clinical change)
• General appearance/LOC: [Appearance], [level of consciousness], [distress level], [odor of substances if present]
• Focused physical exam: [Respiratory effort], [pupils], [tremor], [diaphoresis], [hydration], [signs of trauma or injection sites], [other pertinent findings]
• Mental status exam: [Appearance/behavior], [psychomotor activity], [speech], [mood/affect], [thought process], [thought content including SI/HI], [perceptions], [orientation/attention/memory], [insight/judgment]
• Labs/diagnostics: [Toxicology], [glucose], [EKG], [pregnancy test], [other relevant results] (Include only completed results)
• Monitoring level: [routine / Q15 checks / 1:1 observation / continuous pulse oximetry / cardiac monitoring]

(If restraint or seclusion was used, document: indication, least-restrictive alternatives attempted, type, start/stop times, patient response, and ongoing monitoring.)

Safety & Risk Assessment

(Required whenever any safety concern is present. Do not infer; if not assessed, write "Not assessed: [reason]." Include applicable subsections below.)

Suicide/Self-Harm Risk

• Ideation: [present / absent / unknown]
• Plan: [present / absent / unknown] — [details if present]
• Intent: [present / absent / unknown]
• Behaviors: [recent attempt / preparatory acts / none / unknown] — [details]
• Risk factors: [Crisis-relevant risk factors]
• Protective factors: [Protective factors identified]
• Access to lethal means: [Means identified or denied] — [means safety actions taken]
• Overall risk level: [minimal / low / moderate / high] — [brief rationale]
• Mitigation plan: [Supervision level], [safety plan elements], [referrals], [follow-up timing]

Overdose/Intoxication Risk

• Substances suspected/confirmed: [Substances identified]
• Respiratory and sedation status: [Current status], [airway/breathing assessment]
• Overdose education provided: [yes / no] — [topics covered]
• Naloxone: [offered / dispensed / declined / patient already has / not indicated] — [form if dispensed]

Withdrawal Risk

• Current withdrawal symptoms: [Symptoms present]
• Severity scale: [CIWA-Ar / COWS / other] — [score] — [time] (If used)
• History of severe withdrawal: [seizures / delirium / none / unknown]
• Monitoring and escalation plan: [Vital sign frequency], [medication thresholds], [escalation criteria]

Violence Risk

(Include this subsection only if violence risk is present or requires assessment)

• Homicidal ideation: [present / absent / unknown] — [target if identified]
• Plan and access to weapons: [Details or denied]
• Recent violent behavior: [present / absent / unknown] — [details]
• Mitigation steps: [De-escalation], [environment modification], [security involvement], [duty to warn actions if applicable]

Safety disposition statement: [Clear statement: safe for discharge with safety plan / not safe for discharge – transfer to ED / admission / detox placement / involuntary hold] — [brief rationale]

Crisis Interventions

(Document interventions chronologically with times when available. If no interventions beyond assessment, state explicitly.)

• [Time] — [Engagement/de-escalation approach] — [patient response]
• [Time] — [Brief intervention: topics discussed, harm reduction counseling, patient's stated goals]
• [Time] — [Medication: name, dose, route, indication, response]
• [Time] — [Overdose response: naloxone administered or dispensed, education provided]
• [Time] — [Withdrawal management: medications, monitoring frequency]
• [Time] — [Care coordination: social work, peer support, detox placement, shelter, transportation]
• [Time] — [Means restriction actions and outcomes]

Assessment

(List working diagnoses in problem-oriented format, highest acuity first. Include severity specifiers and supporting evidence. Note differentials when clinically meaningful.)

• [Diagnosis 1]: [Severity] — [Key supporting evidence]
• [Diagnosis 2]: [Severity] — [Key supporting evidence]
• Differential diagnoses: [If applicable, list with brief rationale]

Plan & Disposition

• Disposition decision: [discharge with supports / transfer to ED / admission / detox placement / involuntary hold] — [rationale tied to safety and clinical needs]
• Safety planning: [Safety plan created/reviewed], [crisis line provided], [follow-up contact plan], [means safety actions] (If applicable)
• Medication plan: [Medications started, stopped, or continued], [risk counseling provided], [PDMP reviewed: yes/no]
• Harm reduction: [Naloxone provided], [safer use counseling], [overdose prevention education], [other harm reduction supplies]
• Follow-up: [Specific timing], [provider/service], [location], [contact instructions]
• Return precautions: [Explicit triggers: worsening withdrawal, confusion, suicidal ideation, chest pain, difficulty breathing, signs of overdose]
• Capacity and informed choice: [Capacity assessment if applicable]; [if patient refuses recommended care: risks explained, alternatives offered, refusal documented]
• Patient understanding: [Teach-back summary or patient statement indicating understanding]
• Why discharge is safe: [Supports in place], [monitoring plan], [access to medications], [instructions if risk returns] (Required if discharging)

Time & Services

• Total encounter time: [Start time – Stop time] or [Total minutes]
• Services performed: [Urgent assessment], [mental status exam], [crisis psychotherapy/brief intervention], [resource mobilization], [care coordination], [disposition planning]

Signature

Clinician name and credentials: [Name, degree, license]