Methadone OTP Intake & Care Plan Note

Date/Time: [Encounter date and time]

Location: [Clinic/site name]

Visit Type: [in-person / telehealth]

Author(s): [Name(s), credentials, role(s)]

Encounter Purpose: [Brief purpose statement] (Example: "Initial OTP intake for MOUD initiation and care planning." Modify for transfer intake, pregnancy-related stabilization, or other context as appropriate.)

Chief Concern

[Patient-stated reason for presenting] (Include brief patient quote if it adds clarity. Note visit context: new intake, transfer from another OTP, relapse risk, pregnancy-related stabilization, etc.)

Information Sources

[Sources used: patient report, prior OTP records, PDMP query with date, pharmacy records, collateral contacts with consent noted] (Include reliability statement if history limited by intoxication, withdrawal, cognitive impairment, or language barriers. If prior OTP dosing cannot be verified, explicitly state "unverified" and document risk-mitigation steps.)

Consent & Program Orientation

(If any item not completed, indicate plan and timeframe.)

• Informed consent for methadone: [completed / offered / declined / pending] [brief notes if needed]
• Releases of information: [completed / offered / declined / pending] [entities requested]
• Program orientation: [completed / offered / declined / pending]
• Communication preferences: [completed / pending] [preferred methods, language, interpreter needs]

Safety Triage

(If any positive findings, document clinical response and disposition.)

• Imminent risk screen: [negative / positive for suicidality / homicidality / acute psychosis / severe intoxication or sedation] [details if positive]
• Overdose risk factors: [recent nonfatal overdose / using alone / concurrent sedative use / recent incarceration or hospitalization / reduced tolerance / chronic pulmonary disease / none identified] [details]
• Naloxone access: [has supply / provided today / prescription sent / declined] [training provided: yes / no]
• Clinical response if risks identified: [actions taken, monitoring plan, disposition]

Initial Medical Examination (Screening)

OUD Diagnosis Confirmation

[Statement confirming patient meets OUD criteria for OTP admission] (Briefly note key supporting features: pattern of use, loss of control, tolerance/withdrawal, functional impairment. Indicate current status: actively using, in remission with high relapse risk, or other.)

Medical Screening

• Allergies: [Allergies and reactions, or "No known drug allergies" if explicitly confirmed]
• Current medications: [Medication list] (Highlight sedatives and CNS depressants.)
• Relevant comorbidities: [respiratory disease / hepatic impairment / cardiac or QTc risk / sleep apnea / none identified] [brief notes]
• Pregnancy status: [reported status] [test performed / offered / declined] [result if applicable]
• Vitals: [BP, HR, RR, Temp, SpO2]
• Focused exam: [General appearance, cardiopulmonary, neuro/mental status findings]
• Clinical impression: [intoxicated / in withdrawal / at baseline]

Withdrawal/Sedation Assessment

• COWS score: [score] [mild / moderate / severe] [time assessed] (Include if obtained.)
• Sedation signs: [respiratory rate, pupil size, speech, mental status findings]

Initial Testing

• Toxicology: [ordered / obtained] [specimen type] [collection time] [preliminary results if available]
• Infectious disease screening: [HIV / hepatitis / syphilis] [accepted / declined] [order date]
• Baseline labs: [ordered / obtained / not indicated] [rationale if ordered]
• ECG/QTc: [ordered / obtained / not indicated] [QTc result if available] [indication for screening]

Methadone Initiation Decision

Decision: [initiating today / deferred]

• If initiating: Initial dose [mg]; observed dosing plan [details]; monitoring plan [sedation/respiratory check timing]; rationale [including consideration of fentanyl exposure, tolerance, co-sedatives]
• If deferred: Rationale [e.g., intoxication, unverified dosing, safety concerns]; interim risk-mitigation plan [naloxone, return timing, linkage, observation]

History & Physical

(If full H&P deferred, specify pending elements and scheduled completion date within 14 days per federal standards.)

Opioid Use History

• Timeline and pattern: [substance type(s) including fentanyl exposure, route, quantity, frequency, last use date/time]
• Withdrawal pattern: [typical symptoms, timing of onset]
• Overdose history: [number, circumstances, naloxone use]
• Periods of abstinence: [durations, supports utilized]
• Prior MOUD: [methadone / buprenorphine / naltrexone] [doses tried, response, reasons for discontinuation]
• Transfer details (if applicable): [last observed dose, date/time, verification status and source]

Other Substance Use

• Alcohol: [pattern, quantity/frequency, patient goals]
• Benzodiazepines/sedatives/gabapentinoids: [pattern, patient goals] (Focus on substances affecting methadone safety.)
• Stimulants: [pattern, patient goals]
• Cannabis/nicotine: [pattern, patient goals]
• Other: [details]

Psychiatric History

• Diagnoses and current symptoms: [brief list]
• Current psychiatric medications: [list with adherence status]
• Treatment history: [hospitalizations, therapy engagement]
• Suicide risk history: [prior attempts/ideation] (Include if relevant.)

Medical History

• Chronic conditions: [list]
• Surgical history: [list]
• Pain conditions: [location, severity, current treatments]
• Infectious disease status: [HIV / HCV / HBV status if known]
• OB/Gyn history (if applicable): [pregnancies, contraception, prenatal care]
• Current medications: [complete list] (Reconcile with screening section.)

Social History & Recovery Environment

• Housing: [status, stability, barriers]
• Transportation: [access to OTP, barriers]
• Employment/income/food security: [status]
• Legal involvement: [current status, supervision requirements]
• Social supports: [identified supports, safety concerns]
• Patient strengths: [skills, supports, motivators]

Review of Systems

[Problem-focused ROS by system] (Include only systems reviewed; omit systems not assessed.)

Physical Exam

• Vitals: [BP, HR, RR, Temp, SpO2, Weight, Height, BMI if obtained]
• General: [appearance, distress level, nutritional status]
• Cardiopulmonary: [heart and lung findings]
• Neurologic/Mental Status: [alertness, orientation, speech, mood, affect]
• Additional focused findings: [as indicated by history]

Standardized Assessments

(Include only tools administered. If a tool was not administered and this is clinically relevant, briefly note reason.)

• [Tool name]: [date, score, severity interpretation, impact on plan]

Synthesis: [Brief integration of key risk drivers and engagement barriers across medical, psychiatric, and social domains; note limitations such as self-report reliability or incomplete records]

Objective Data Summary

• Vitals: [values with time]
• Withdrawal score: [COWS score, time]
• Mental status: [alertness, orientation, speech, affect]
• Toxicology: [collection time, results or pending status]
• PDMP query: [date, relevant findings such as concurrent sedatives or overlapping prescriptions]
• Labs/ECG: [results with dates; pending items with expected timeframe]

Assessment

1. Opioid Use Disorder: [severity] [brief "why now" summary: precipitating factors, current risks, goals]
2. Other SUDs affecting methadone safety/treatment: [diagnoses or patterns; impact on plan]
3. Psychiatric conditions affecting engagement: [diagnoses, current status]
4. Medical problems relevant to dosing/safety: [respiratory / hepatic / QTc / pregnancy / other]
5. Overdose risk formulation: [concrete risk factors; protective factors]

(Do not assert abstinence, medication adherence, pregnancy status, or transfer dose accuracy without explicit supporting documentation.)

Care Plan

Shared Decision-Making: [Statement confirming care plan developed collaboratively with patient preferences elicited and incorporated]

Patient Goals

• Short-term: [patient-voiced goals, e.g., reduce withdrawal/cravings, stop fentanyl use, reduce overdose risk]
• Longer-term: [patient-voiced goals, e.g., housing, employment, family reunification, mental health stability]

Mutually Agreed Actions

• Patient will: [attend dosing schedule, complete labs/tox, participate in counseling/peer support if desired, follow safe storage practices] [timelines]
• OTP team will: [dosing/titration approach, monitoring frequency, referrals to place, care coordination contacts, peer navigation] [timelines]

Methadone Plan

• Initial dose: [mg] [rationale including tolerance assessment and co-sedative considerations]
• Titration approach: [increment size, interval, criteria for adjustments]
• Observed dosing schedule: [daily observed dosing details]
• Monitoring plan: [sedation/respiratory check timing and parameters]
• Drug interaction counseling provided: [CNS depressants, alcohol, other interactions reviewed]
• Missed-dose policy reviewed: [yes / no]
• Take-home status: [not yet eligible / criteria and target date for eligibility review]

Harm Reduction Interventions

• Overdose education: [provided / offered / declined / already has]
• Naloxone and training: [dispensed / prescribed / declined / already has] [recipient: patient / support person]
• Safer use counseling: [provided / offered / declined]
• Fentanyl test strip education: [provided / offered / declined / not available]
• Infectious disease prevention: [testing offered / vaccinations offered / referred]
• Take-home medication safety: [provided / offered / declined]

Recovery Support Services

• Peer recovery support: [need identified / referred / scheduled / declined / not indicated]
• Case management: [need identified / referred / scheduled / declined / not indicated]
• Housing resources: [referred / information provided / declined / not indicated]
• Food/benefits/transportation: [referrals or supports arranged]
• Employment/vocational support: [referred / declined / not indicated]
• Legal aid/family support: [referred / declined / not indicated]
• Primary care linkage: [established / referred / appointment date]
• Mental health services: [established / referred / declined] [provider if known]

Follow-Up Plan

• Next dosing: [date/time and monitoring checks]
• Medical follow-up during induction: [24-72 hour check if indicated; appointment date/time]
• Counseling/peer visit schedule: [frequency and start date if patient desires]
• Pending results review: [responsible party and timeframe]
• Care plan review interval: [timeline for reassessment]

Education Provided

• Methadone effects and accumulation risk during early treatment: [provided / declined]
• Sedation warnings and avoiding CNS depressant combinations: [provided / declined]
• Safe medication storage and transport: [provided / declined]
• Instructions for worsening withdrawal or excessive sedation: [provided / declined]
• Missed dose instructions: [provided / declined]
• Written materials provided: [list]
• Patient understanding: [adequate per teach-back / needs reinforcement]

Orders & Referrals

• Labs ordered: [tests with rationale]
• Toxicology ordered: [specimen type, collection details]
• ECG: [ordered / not indicated] [reason]
• Naloxone: [dispensed / prescribed / declined] [formulation and quantity]
• Referrals placed: [PCP / OB / psychiatry / counseling / peer support / housing / other] [dates and contacts]
• Records requested: [prior OTP / PCP / pharmacy / other] [date requested, ROI status]

Confidentiality Notice: This record contains substance use disorder information protected by 42 CFR Part 2 and applicable state laws. Redisclosure is prohibited without specific patient consent, except as permitted by law.