Opioid Use Disorder Medication-Assisted Treatment Follow-Up Note

Visit Information

Date of Service: [Date]

Visit Type: [in-person / telehealth]

Provider: [Name, credentials]

Diagnoses Addressed: [Diagnoses addressed this visit]

Chief Concern

[Concise statement of visit purpose specifying opioid use disorder and the specific MOUD being monitored]

Interval History

[Narrative summary of interval course since last visit] (2–4 sentences covering overall stability, current MOUD regimen and adherence, cravings/withdrawal control, and any interval opioid or other substance use.)

MOUD Status: [Current medication, dose, formulation; adherence including missed doses and barriers; perceived effectiveness; patient experience]

Cravings/Withdrawal: [Severity, triggers, functional impact; standardized scale score if used]

Interval Substance Use: [Opioid use since last visit including last use date, route, fentanyl exposure concern; other substances affecting overdose risk or treatment] (Document as "per patient report" unless corroborated by testing.)

Side Effects/Interactions: [MOUD-specific tolerability issues and concerning medication interactions]

Harm Reduction: [Naloxone access and training status; overdose risk behaviors; safer use counseling provided]

Recovery Supports: [Counseling or peer support engagement; barriers; whether offered, engaged, declined, or unavailable]

Other Considerations: [Pregnancy/contraception status, acute pain planning, infectious risk screening] (Only include if clinically relevant to this visit.)

Objective

Vitals/Appearance: [Vitals if collected; observed signs of intoxication, withdrawal, or sedation] (Omit if not obtained.)

Exam: [Focused findings: mental status, respiratory effort, pupils, injection sites as relevant] (Omit if no exam performed.)

Toxicology: [Test type and specimen; date collected; results by analyte as positive/negative; expected vs. unexpected findings; brief clinical interpretation acknowledging limitations] (If not obtained, document reason and plan.)

PDMP Review: [Date reviewed; whether fills are consistent with expectations; other controlled substances or concerning patterns] (If unable to access, document barrier and mitigation plan.)

Assessment & Plan

Opioid Use Disorder on MOUD

[Clinical status summary] (Include cravings/withdrawal control, interval substance use per patient report, toxicology/PDMP concordance, engagement, and key safety risks. If concern for diversion/nonadherence, document objective basis and alternative explanations.)

• Medication plan: [Continue / adjust dose / change formulation with rationale; medication name, formulation, dose, quantity, refills]
• Monitoring plan: [Visit frequency; toxicology and PDMP review schedule; diversion mitigation if indicated]
• Harm reduction: [Naloxone prescribed/confirmed; overdose prevention counseling topics]
• Counseling/supports: [Referrals offered or continued engagement] (Document that MOUD continues regardless of counseling participation.)
• Contingency planning: [Instructions if return to use occurs; criteria for urgent evaluation]

[Additional Problems]

[Brief assessment of co-occurring substance use, mental health, or relevant medical issues with implications for OUD treatment and safety]

• Plan: [Targeted management steps, referrals, and monitoring]

Follow-Up

Next Appointment: [Interval and modality]

Return Precautions: [Overdose or near-overdose, severe sedation or respiratory symptoms, severe withdrawal with high risk of return to use, new suicidality, inability to access medication, severe injection site reaction if applicable]

(Use person-first, non-stigmatizing language throughout. Report toxicology as positive/negative. Refer to "interval opioid use" rather than "relapse." When expected data is unavailable, document reason and mitigation plan rather than omitting. Do not infer abstinence from absence of data; distinguish patient report from objective corroboration.)