MOUD/MAT Coordination Note (Counselor)
A concise coordination note for counselors documenting MOUD-related communication with prescribers and OTP staff. Covers consent status, medication adherence, patient-reported effects, care team communications, and integ…
Document Type
clinical note / Progress Note
Specialties
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MOUD/MAT Coordination Note
Date: [Date]
Author: [Name, credentials]
Encounter type: [in-person / video / phone / secure message / case conference / collateral only]
Participants: [Patient; prescriber; OTP staff; others present]
(This is a care-coordination record for the treatment team. Exclude psychotherapy process content and verbatim dialogue.)
Consent & Information Sharing
[Consent/ROI status: active / expired / not on file / not verified] (If active, note allowed parties and key restrictions. If not verified or not on file, state disclosure limitations.)
MOUD Status & Patient Report
- Current MOUD regimen: [Medication, formulation, dose, frequency] (Note source: patient report / prescriber note / OTP record / EHR.)
- Adherence since last contact: [Summary of adherence, missed doses, late pickups, early run-outs] (Distinguish patient report from objective data.)
- Response/benefits: [Craving control, stability, functioning as reported]
- Side effects or concerns: [Reported adverse effects or tolerability issues] (If none reported, document "Denies.")
- Barriers to MOUD engagement: [Relevant access, psychosocial, or logistical barriers] (Note intervention or escalation if applicable.)
- Overdose risk/naloxone: [Naloxone on hand, education reviewed, risk factors if present] (Include only if assessed or clinically indicated.)
(For items not covered, note "Not assessed today" with plan for next contact.)
Coordination Summary
(Document each coordination contact. Keep to minimum necessary within consent scope.)
- Contact: [Name, role] via [method] — [reached / pending]
- Purpose: [Reason for coordination]
- Information shared: [Current regimen, adherence, side effects, safety signals as relevant]
- Decisions/requests: [Dose review, appointment, naloxone Rx, care plan updates, etc.]
(Repeat structure for additional contacts as needed.)
Plan
- Patient: [Actions, appointments, refill dates, adherence strategies]
- Counselor: [Next outreach, reminders, referrals, monitoring plan]
- Prescriber/OTP: [Requested actions, pending appointments, follow-up timeline]
Next counselor contact: [Date or timeframe]
Next prescriber/OTP appointment: [Date or pending]
Safety/escalation plan: [Overdose risk education, naloxone access, crisis steps] (Include only if safety concerns present.)
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