MOUD Monitoring & Adherence Risk Mitigation Note

Focused MOUD (Medications for Opioid Use Disorder) Monitoring & Adherence Risk Mitigation Note

(Use this template only when elevated overdose risk, diversion risk, or adherence concerns are present—not for routine MOUD follow-up.)

Visit Information

Visit Date: [Visit date]

Clinician: [Clinician name and credentials]

Visit Type: [in-person / video / phone] — [Location/site if applicable]

Current MOUD: [Medication, formulation, dose, route, schedule]

Reason for Focused Monitoring Note: [One-line summary of triggering concern]

Interval Since Last Visit/Fill: [Time interval, if known]

Focused Monitoring Summary

(Brief executive summary; detailed documentation follows in subsequent sections.)

1) What raised concern? [Triggering concern with specific data sources] (Use neutral language; include dates/times if known.)

2) Objective data reviewed today: [List data sources reviewed: PDMP, toxicology, pill/film count, pharmacy verification, collateral information]

3) Risk-mitigating actions taken today: [Prescribing safeguards, monitoring changes, safety counseling, care coordination, referrals]

4) Monitoring plan going forward: [Visit frequency, toxicology schedule, PDMP cadence, escalation/de-escalation criteria]

Interval History & Adherence

[Patient-reported adherence since last visit] (Include missed doses, timing deviations, withdrawal between doses, cravings, and barriers such as side effects, housing instability, or routine disruption.)

[Patient-reported substance use since last visit] (Include opioids/fentanyl, benzodiazepines, alcohol, stimulants, cannabis; note route, frequency, and last use when clinically relevant.)

[Overdose or near-overdose events, naloxone use, ED/EMS encounters] (Include dates if known.)

[Early refill requests or lost/stolen reports, if applicable] (Document who reported, when, circumstances, and corroboration if any. Use direct quotes for high-stakes statements when helpful.)

[Patient-stated goals and preferences regarding care]

(If key details cannot be obtained, document "Unable to obtain" with reason and plan to obtain later.)

Medication Reconciliation

MOUD: [Medication, dose, route, schedule]

Controlled and sedating co-medications: [List each medication with prescriber and indication] (Include benzodiazepines, Z-drugs, gabapentinoids, muscle relaxants, other opioids, stimulants. Omit categories not applicable to this patient.)

High-risk combinations and counseling: [Note combinations that elevate overdose risk and safety counseling provided]

(If full reconciliation not confirmed, document sources used—patient report, pharmacy, EHR—and what remains uncertain. If not performed, document "Not completed" with reason and plan.)

PDMP Review

PDMP Checked: [Date, time, state(s) queried]

Findings: [Last MOUD fill: date, quantity, days' supply, pharmacy] | [Other controlled substances: prescriber count, overlap patterns, high-risk combinations]

Consistency: [Consistent / Inconsistent] with agreed treatment plan

Actions Taken: [Coordination with other prescribers, counseling, dispensing adjustment, or none required]

(If PDMP not accessible, document attempt, reason for failure, and interim safety plan.)

Toxicology Monitoring

Specimen & Collection: [Urine / Oral fluid] — [Observed / Unobserved] — [Random / Scheduled] — [Collection date/time]

Test Type: [Point-of-care presumptive / Definitive confirmatory]

Validity: [Temperature, creatinine, specific gravity, adulterants, if available]

Expected Results: [Based on prescribed regimen and patient report]

Actual Results: [Summary with unexpected findings highlighted]

Interpretation: [Differential explanation] (Consider timing, metabolism, assay limitations, missed doses, absorption, or specimen factors. Do not conclude diversion or misuse from a single data point unless confirmed.)

Response Plan: [Confirmatory testing if needed; patient discussion using non-punitive framing; adjustments to monitoring intensity or level of care]

(If toxicology was not obtained, document reason and plan for future testing.)

Pill/Film Count

(Include this section when a count was performed or when indicated but not performed. Omit if not applicable to this encounter.)

Count Performed: [Yes / No]

Method: [In-clinic / Video verification] — [Announced / Unannounced] — [Performed by]

Calculation: Fill date [date] | Quantity dispensed [number] | Prescribed daily dose [dose] | Expected remaining [number]

Observed Count: [Number observed]

Discrepancy: [None / Discrepancy magnitude and details]

Patient Explanation: [Patient statement, quote if helpful]

Action Taken: [Dispensing frequency change, unannounced counts, observed ingestion, formulation change consideration, OTP referral, or other with rationale]

(If not performed when indicated, document reason and alternative risk mitigation used.)

Focused Exam

(Include only if clinically indicated. Omit this section entirely if no exam was performed and none was indicated.)

[Relevant vitals] (Related to sedation risk, withdrawal, or intoxication.)

[Physical exam findings] (Signs of intoxication, withdrawal, or injection sites if relevant.)

[Mental status or safety screen] (If indicated.)

[Pertinent labs reviewed today] (If influencing management.)

Risk Formulation

Overdose Risk Factors: [List applicable: sedative co-use, recent overdose, fentanyl exposure, return to use after abstinence, low tolerance, mixing substances, living alone, unstable medical comorbidities]

Diversion Risk Factors: [List applicable: repeated lost/stolen reports, count discrepancies, absence of expected MOUD metabolite, unsafe storage, others accessing medications, financial instability]

Protective Factors: [List applicable: engagement in care, stable housing, locked storage, supportive family, consistent toxicology, consistent PDMP]

Synthesis: [One to two sentences integrating factors into overall risk assessment using neutral language]

Assessment

1. Opioid Use Disorder on MOUD — [stable / partially stable / unstable] — [Brief rationale]
2. Adherence Concern — [Specify evidence sources: PDMP, toxicology, count, patient report, pharmacy]
3. Co-occurring Substance Use Risks — [Specify substances and concerns, especially sedatives, alcohol, non-prescribed opioids]
4. [Additional relevant problems, if applicable] (Psychiatric comorbidity, chronic pain, social instability, pregnancy.)

(If continuing MOUD despite concern, document clinical rationale and risk-mitigation steps. If changing MOUD or escalating care, document safety rationale and alternatives discussed.)

Plan

MOUD Prescribing: [Continue / Adjust dose / Change formulation] — [Rationale] — Dispensing: [daily / 3-day / weekly / biweekly / monthly; partial fills if used] (Reinforce refill policy for lost/stolen or early requests.)

Monitoring Schedule: Visit frequency [frequency/modality] | Toxicology [frequency, type, random vs scheduled] | PDMP review [cadence] | Pill/film counts [plan if indicated] | Escalation triggers [specify] | De-escalation criteria [specify]

Harm Reduction: Naloxone [prescribed / renewed / confirmed in household] | [Counseling on avoiding mixing MOUD with alcohol, benzodiazepines, sedatives] | [Safe storage plan; child/pet safety; disposal guidance]

Care Coordination: [Contacts made with patient permission: pharmacy, other prescribers, counselors, OTP, case management] (Document ROI status and outcomes.)

Referrals: [Behavioral therapy / Peer support / Intensive outpatient / OTP / Psychiatry / Social services, if indicated]

Follow-up: [Next appointment date/timeframe] | Planned for next visit: [PDMP, toxicology, count, other]

Patient Discussion & Shared Decision-Making

Topics discussed: [PDMP findings, toxicology results, count discrepancies, safety concerns]

Patient response: [Patient perspective and reaction, direct quotes if clarifying]

Options presented: [Increased monitoring, formulation change, higher level of care, other]

Negotiated plan: [Agreed-upon approach reflecting patient preferences] (Document that discussion was framed around safety rather than punishment.)