Methadone OTP Periodic Assessment Note

Date/Time: [date and time]

Author/Credentials: [name, degree(s), license]

Encounter Type: Periodic Assessment (Methadone OTP)

Modality: [in-person at OTP / telehealth] (If telehealth, include patient and clinician locations; if audio-only, note observational limitations in Objective.)

Interval Since Last Periodic Assessment: [interval]

Data Sources: [patient report, chart review, toxicology, PDMP, collateral if any]

Administrative & Safety Verification

• Identity verification: [verified via photo ID / OTP photo and DOB / voice verification and two identifiers / not completed—reason and mitigation]
• PDMP check: [date] — [notable findings / no concerning findings / unable to access—reason and plan]
• Registry/other-OTP enrollment check: [no duplicate enrollment / potential other OTP involvement—actions taken]
• Observed intoxication/sedation screen: [negative / positive—findings and action taken if dosing held or modified]
• Medication reconciliation: [completed / partial / not completed—reason and plan] — Sedatives/QT-prolongers: [current agents or "none reported"]

Subjective

[HPI: reason for visit (periodic reassessment), current methadone dose and schedule (observed vs take-home), overall trajectory since last assessment with 1–2 supporting details]

• MOUD response: [withdrawal control; cravings—frequency, triggers, intensity; sedation or overmedication symptoms; adherence and missed doses; side effects; patient satisfaction with current dose]
• Interval substance use: [opioids—type, route, frequency, last use, overdose events, naloxone use; other substances—alcohol, benzodiazepines, stimulants, cannabis, sedatives with patterns and triggers; correlation with toxicology—note alignment or discrepancies neutrally]
• Psychiatric/medical updates: [mood, anxiety, sleep, trauma symptoms; suicide/self-harm screening result; psychiatric medication adherence; new diagnoses or hospitalizations; pregnancy status if applicable; current sedative or QT-prolonging medications]
• Social determinants and recovery supports: [housing; transportation to OTP; employment; legal involvement; peer support or mutual-help groups; functional gains or challenges]
• Patient-identified goals: [1–3 measurable items for next interval; patient preferences regarding visit frequency, counseling, take-homes, or harm reduction] (If goals not elicited, document why and plan to revisit.)

Objective

Vitals/Observation: [relevant vitals; general appearance; signs of intoxication or withdrawal]

Brief Mental Status: [appearance; behavior; speech; mood/affect; thought process; cognition; insight/judgment]

Toxicology Summary: [summary of random drug test results since last periodic assessment with dates and key positives/negatives; specimen validity and confirmatory testing if applicable] (If insufficient testing, document circumstances.)

Other Monitoring: [QTc/ECG with date if performed; infectious disease and vaccination status; naloxone possession; outside records reviewed if applicable]

Assessment

(Format as problem-oriented list with highest-risk items first. For each problem, include status, key supporting evidence, and clinical interpretation. State observable basis when inferring stability; do not infer patient intent.)

• Opioid Use Disorder on Methadone: [in remission / partial response / ongoing use / unstable] — Evidence: [craving/withdrawal control; attendance; toxicology trends; functional outcomes] — Interpretation: [stability vs risk synthesis]
• Other Substance Use Disorder(s): [substance and status] — Evidence: [use patterns; toxicology; impact] (Include if applicable.)
• Psychiatric condition(s): [diagnosis and status] — Risk: [suicide/self-harm risk level with rationale] (Include if applicable.)
• Medical safety considerations: [QT risk; respiratory disease; hepatic disease; pregnancy; chronic pain—as applicable with relevant monitoring data]
• Overdose and diversion risk: [overdose risk factors and naloxone access; diversion risk indicators and storage/transport practices; adherence barriers and supports affecting risk-benefit for take-homes]

Plan

• Methadone: [continue / increase / decrease / hold] [current or new dose] (Rationale tied to symptoms and objective data. Include titration schedule if changing, monitoring plan, missed-dose policy application if relevant, and safety counseling provided—sedation, driving, interactions.)
• Take-Homes: [current schedule / none—no change / initiating or modifying] (If take-homes provided or changed, document risk-benefit reasoning, safe storage/transport plan and education, diversion mitigation with non-punitive framing.)
• Toxicology: [testing frequency and panel; how results will be reviewed with patient] (If frequency reduced, document clinical rationale.)
• Counseling & Care Plan: [updated goals; services and recommended frequency; referrals to peer support, case management, or therapy] (If patient declines counseling, document what was offered and alternative engagement plan.)
• Harm Reduction: [naloxone prescribed/provided and education; safer use counseling tailored to current risks; linkage to syringe services if applicable]
• Psychiatric/Medical: [screening tools; medication changes; safety plan if risk positive; ECG plan if indicated; infectious disease screening; pregnancy coordination—as applicable]
• Follow-Up: [next OTP medical follow-up; criteria for earlier reassessment—sedation, overdose, return-to-use, pregnancy, hospitalization; patient instructions and emergency guidance]

Clinician Signature: [typed full name], [credentials], [role]

Supervisor Attestation: [attending/supervisor name and credentials] — [attestation statement per local policy] (Include if applicable.)