Relapse/Return-to-Use Event Note

Date/Time: [encounter date and time]

Setting: [clinic / telehealth / ED follow-up]

Participants: [patient and others present]

Data Sources: [patient report / collateral / PDMP / toxicology / external records reviewed]

(Use person-first, non-stigmatizing language throughout. Prefer "return to use" or "recurrence." Describe toxicology as "positive/negative for [substance]." Attribute statements to patient report, collateral, or clinician observation.)

Event Summary

[4–6 sentence clinical snapshot of the episode] (Include: primary substance(s) involved, prior period of abstinence or stability, date/time of return to use and last use, current clinical status [intoxicated / withdrawing / stable], key safety findings such as overdose occurrence or suicidal ideation, and high-level plan changes. Attribute each fact to its source.)

Subjective

Chief Concern: "[patient's stated reason for encounter]"

Timeline of Episode: [start of use, last use date/time, substance(s) and route(s), estimated amount, pattern of use, co-ingestants] (Document "Unknown" when information cannot be obtained.)

Triggers and Antecedents: [emotional, physiologic, social/environmental, or access-related factors preceding use] (Include only factors explicitly stated by patient or collateral.)

Current Symptoms: [intoxication symptoms, withdrawal symptoms, psychiatric symptoms including cravings] (Distinguish patient report from clinician observation.)

Medication and Treatment Status: [MOUD/MAT regimen and adherence, recent changes, engagement with therapy and recovery supports]

Protective Factors: [reasons for living, supportive relationships, recovery strengths, what prompted seeking help today]

Insight and Readiness: [patient's understanding of episode, goals, ambivalence, stated readiness for change, preferences for next steps]

Objective

(Include only elements relevant to this episode.)

• Vitals/Exam: [relevant vitals, general appearance, respiratory status, pupils, signs of intoxication or withdrawal] (If not obtained, state why.)
• Mental Status: [appearance, behavior, speech, mood/affect, thought process/content, cognition, insight/judgment, decision-making capacity]
• Testing: [toxicology type and results, PDMP findings, external records reviewed] (If testing declined or unavailable, document how risk was otherwise assessed.)

Assessment

• Diagnoses: [substance use disorder diagnosis(es) with severity, relevant co-occurring conditions]
• Clinical Interpretation: [characterization of episode: lapse / recurrence / escalating pattern], [key drivers identified], [adequacy of current treatment intensity]
• Risk Assessment:
  • Overdose risk: [low / moderate / high] — [rationale including tolerance changes, polysubstance use, supply potency], [mitigation steps]
  • Withdrawal risk: [low / moderate / high] — [anticipated course and complications], [monitoring plan]
  • Suicide/self-harm risk: [low / moderate / high] — [ideation, plan, intent, means access, protective factors], [mitigation/safety plan]
  • Other risks: [violence, infectious disease exposure, pregnancy considerations] (Include only when clinically indicated.)
• Level of Care: [clinical reasoning for current level / step up / step down], [patient preference], [shared decision-making outcome]

Plan

• Disposition: [safe for home with supports / same-day urgent evaluation / ED transfer / higher level of care], [who notified], [transport plan] (If patient declines recommended higher level of care, document capacity, risks discussed, alternatives offered, and close follow-up plan.)
• Harm Reduction: [naloxone provided and training offered, overdose response education, safer use counseling, syringe services referral if injection use, infectious disease testing if indicated] (Document patient agreement or declination.)
• Medication Changes: [MOUD/MAT initiation or adjustment, withdrawal or symptom management, patient understanding]
• Treatment Adjustments: [visit frequency changes, therapy focus, referrals, linkage to recovery supports or peer services]
• Follow-up: [next appointment], [crisis resources including 988], [overdose response instructions], [plan for renewed cravings]

(Document patient agreement or declination for each intervention. Use clear source attribution throughout.)