SUD Treatment Plan Review/Update Note
A concise template for periodic SUD treatment plan reviews, emphasizing interval changes rather than restating the full plan. Structured to document progress toward goals, updated risk assessment, and explicit plan modif…
Document Type
clinical note / Progress Note
Specialties
Template Preview
Date of Service: [date]
Author: [name, credentials, role]
Location/Modality: [in-person / video / audio-only]
Participants: [patient; others present with consent noted]
Review Context & Interval Summary
[Reason for review: routine periodic / triggered by event] — [prior treatment plan date] — [review interval dates]. [Patient participation and endorsement of updates confirmed]. (Use exact dates when available.)
[Substance use course since last review: substances used; frequency/quantity changes; last use date; cravings/triggers; periods of abstinence; overdose events or naloxone use] (Use objective anchors with dates.)
[Functioning and engagement: housing; employment/education; legal status; social supports; service attendance; key barriers; facilitators supporting recovery] (If information not obtained, state why.)
Objective Data
(Include only data obtained during the review interval. If no new data, state "No new objective data obtained this interval" with explanation.)
- Observations: [date — relevant mental status findings; intoxication/withdrawal signs if present]
- Toxicology: [specimen type — date — results — clinical interpretation]
- Other Labs/Measures: [test/tool — date — result — interpretation]
Progress Toward Goals
(List active problems in descending order of severity/risk. Repeat block for each active problem.)
Problem: [problem linked to diagnosis]
Goal: [patient-centered goal, in patient's words when possible]
Status: [Achieved / Improving / No Change / Worsening]
Evidence: [dated objective anchors supporting the rating]
Barriers/Facilitators: [key factors affecting progress]
Decision: [continue / revise / retire] — [brief rationale]
Risk Assessment
[Suicide/self-harm: current ideation, plan, intent, risk and protective factors] [Overdose risk: recent events, polysubstance use, tolerance changes, naloxone access] [Withdrawal/medical instability: current symptoms, seizure/DT history, need for higher level of care] [Violence/victimization concerns if clinically relevant] (If any domain not assessed, document reason and follow-up plan.)
Risk Level: [low / moderate / high] — [brief justification]
Mitigation Plan: [specific safety actions: safety plan updates, crisis contacts, dosing changes, referrals, harm reduction interventions]
Treatment Plan Updates
Changes Made
(If no changes: "Plan unchanged; continue current interventions.")
- [What changed] — [why: link to progress/risk/barriers/preferences] — [effective date] — [how success will be measured]
Active Plan Summary
- Active Problems & Goals: [brief list of current problems linked to goals]
- Services/Interventions: [service type — frequency — provider/setting]
- Care Coordination: [collaboration with other providers; referrals; releases of information]
Medical Necessity: [1–2 sentences: why continued services at current intensity are needed, or why step-up/step-down is indicated]
Medications: [current SUD-related medications, adherence, changes, monitoring plan] (Omit section if no SUD medications.)
Patient Endorsement: [patient understanding and agreement with updates; if disagreement, note risks explained and negotiated plan]
Next Review: [specific date] or sooner if [contingency triggers]
Follow-Up Appointments: [next scheduled services and responsible clinician]
Signature
Clinician Signature: [name/credentials]
Date/Time: [timestamp]
Co-signature: [supervising clinician if applicable]
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