Overdose Risk Assessment & Harm Reduction Counseling Note

Encounter Type: [harm-reduction visit / overdose risk assessment / counseling visit]

Date/Time: [Date and time of encounter]

Location/Setting: [clinic / community outreach / emergency department / inpatient / telehealth / other]

Participants: [patient; support person(s); peer navigator; interpreter if used with language noted]

Reason for Visit: [One-line summary]

Chief Concern / Patient Goal

[Patient-stated reason for visit and immediate priorities] (Summarize in 1–3 sentences. Quote patient's own words when available. Reflect what the patient wants from the encounter, such as access to naloxone, safer use strategies, concern about recent overdose, using alone, or interest/non-interest in treatment.)

History of Present Encounter

[Brief narrative of trigger for visit, current substance use pattern, recent changes, and today's priorities/readiness] (Use person-first, non-stigmatizing language. Include trigger for visit such as recent overdose, supply changes, release from incarceration, hospital discharge, return to use after abstinence, or concern from others. Describe current substances, routes, frequency, amounts, and what has changed. Label data sources as patient-reported, observed, or record-based.)

Overdose Risk Assessment

(Document only what was assessed today. Do not auto-populate negatives without explicit confirmation. For items not obtained, use: "Not assessed [reason]", "Patient declined", or "Unknown".)

• Substance Use Profile: [Primary substances (names, forms, amounts, frequency, last use); routes of use and recent changes; source predictability (known/unknown supply, counterfeit pills); polysubstance use (alcohol, benzodiazepines, sedatives, stimulants, gabapentinoids); recent abstinence or tolerance changes (detox, hospitalization, incarceration, reduced use); frequency of using alone; access to someone who can respond]

• Overdose History: [Number of prior overdoses, timing, suspected substances, whether naloxone was administered, EMS/ED involvement; prior naloxone experience (administered to self or others), barriers, fears about precipitated withdrawal]

• Medical and Contextual Risk Modifiers: [Respiratory/cardiac conditions (COPD, sleep apnea); pregnancy/postpartum if applicable; renal/hepatic disease; relevant mental health factors; suicidality screen if intentional overdose risk suspected; social context (housing instability, barriers to calling EMS, using alone, isolation)]

• Risk Tier (optional): [Low / Moderate / High / Very High] (If documented, provide brief rationale citing 3–6 key risk drivers traceable to factors above. Omit section entirely if not determined.)

Objective

(Include only what was obtained. If limited by setting, state: "Objective data limited by setting.")

• Vitals and Appearance: [Vital signs if obtained (respiratory rate, O2 saturation, HR, BP); level of alertness; signs of intoxication or withdrawal; general appearance]
• Focused Exam (if performed): [Respiratory effort; injection sites or wounds (location, appearance, infection signs); mental status for capacity assessment] (Omit if not performed.)
• Data Reviewed (if applicable): [PDMP findings; medication list; recent labs or ED notes; point-of-care test results] (Specify dates and sources.)

Harm Reduction Counseling Provided

(Document topics addressed and how counseling was tailored to this patient's substances, routes, and context. If patient declined counseling, document what was offered, the refusal, and any minimal safety information accepted.)

• Overdose Prevention Topics Addressed: [Risks discussed: using alone, unknown potency/supply changes, mixing opioids with CNS depressants, tolerance changes after abstinence, route changes. Safer practices discussed: test doses ("start low, go slow"), staggering polysubstance use, ensuring someone can check in or using "never use alone" services, keeping naloxone accessible]

• Drug Checking Counseling (if applicable): [Fentanyl test strip use and interpretation; limitations discussed (cannot quantify dose, does not guarantee safety); xylazine counseling if relevant to local supply (naloxone may not reverse effects but should still be given, emphasis on rescue breathing and calling EMS)]

• Safer Injection Counseling (if applicable): [Sterile equipment use; site rotation; wound care warning signs; referral to syringe services program]

• Patient Understanding: [Teach-back or demonstration outcome] (Example: "Patient demonstrated naloxone nasal spray administration using trainer device" or "Patient verbalized overdose response steps accurately." If teach-back not possible, document reason.)

• Materials Provided: [Handouts, instructions, or educational materials given; language or format accommodations if relevant]

Naloxone Access and Education

• Current Access: [Patient's current naloxone supply; where stored/carried; barriers (cost, stigma, transportation, lost/confiscated, prior adverse experience)]
• Provided Today: [Prescribed / Dispensed / Not provided] (If prescribed: product, formulation, quantity, refills, pharmacy. If dispensed: product, quantity, lot number and expiration if required. If not provided: document reason. If declined: document capacity, risks explained, and patient's reasoning.)
• Training Provided: [Indications for use (including when uncertain if opioids involved); overdose recognition (respiratory depression, unresponsiveness); administration steps for specific formulation; repeat dosing timing; rescue breathing and recovery position; calling EMS; expected effects including possible withdrawal and symptom recurrence]
• Bystander Training (if applicable): [Family/friends/caregivers present offered or received training; acceptance/decline; materials provided]

Patient-Specific Overdose Response Plan

(Document a concrete, individualized plan in plain language.)

• Context: [Where overdose is most likely to occur; relevant constraints (using alone, fear of calling EMS, unstable housing)]
• Response Plan: [Who can respond (named person or "trusted contact") and how reached; where naloxone will be kept; stepwise actions: check responsiveness and breathing → give naloxone → call 911 → rescue breaths or recovery position → repeat dose if no response → stay with person until help arrives]
• Contingencies: [Plan if using alone (check-in service, keeping door unlocked, calling someone before use); plan if naloxone ineffective or xylazine suspected (rescue breathing, EMS activation)]
• Patient Agreement: [Elements agreed to; elements declined with rationale]

Linkage to Treatment and Resources

(Document as offered / accepted / declined for each item addressed.)

• Treatment: [Medications for opioid use disorder (MOUD) offer or referral; stimulant use disorder supports if applicable; patient's motivational stance and plan to re-offer if not ready]
• Infectious Disease Prevention: [HIV/HCV testing and linkage; hepatitis A/B vaccination; STI screening if relevant]
• Harm Reduction Services: [Syringe services program; wound care clinic; peer support and recovery resources]
• Practical Supports (if addressed): [Housing; food assistance; insurance navigation; transportation; legal aid]
• Crisis Resources (if indicated): [Crisis line information; urgent behavioral health referral; safety plan if mental health risk identified]

Assessment

[Relevant diagnoses, conditions addressed, and risk factors] (Clearly distinguish confirmed diagnoses from suspected conditions and from risk factors or social needs. Do not diagnose substance use disorder without documenting diagnostic basis. Examples: opioid use disorder with documented criteria met, overdose risk counseling encounter, polysubstance use, history of overdose, injection-related wound, housing insecurity.)

Plan

(Consolidated, problem-oriented format with highest-risk issues first.)

• Overdose Risk Mitigation: [Naloxone plan (prescribed/dispensed/training completed); overdose response plan summary; safer use steps patient agreed to]
• Wounds/Infections (if applicable): [Care plan; signs warranting urgent evaluation]
• Testing/Immunizations: [Orders placed or referrals for HIV/HCV/STI testing; hepatitis A/B vaccination]
• Treatment Linkage: [Referrals made (MOUD, behavioral health, peer support); follow-up plan and timeframe]
• Return Precautions: [Symptoms after reversal requiring return; wound infection signs; chest pain or overamping symptoms if stimulant use; breathing concerns]
• Follow-Up: [Next contact method and date/time; patient's preferred contact method; contingency if contact missed]

Time and Billing (if applicable)

• Total clinician time: [Minutes]
• Major activities: [Counseling; naloxone training; care coordination; chart/PDMP review; documentation]
• Billing code(s): [If applicable]

(Use person-first, non-stigmatizing language throughout. Label data sources as patient-reported, observed, or record-based. For items not assessed, document "Not assessed [reason]" or "Patient declined" rather than omitting silently or inferring negatives. If the patient declines any intervention, document capacity, risks discussed, and patient's reasoning. If encounter scope is limited, collapse Objective and focus on counseling, naloxone, and response plan. Omit inapplicable sections rather than leaving them empty.)