Treatment Plan Review/Update (SUD)

Note Type: Treatment Plan Review/Update (SUD)

Review Type: [scheduled interval / triggered] (If triggered, specify precipitating event.)

Review Period: [start date] through [end date]

Date of Review: [date]

Program/Setting: [OTP / IOP / outpatient / residential / other]

Participants: [patient, family/supports present, care team members, interpreter, external parties such as probation or case management]

Information Sources: [patient report, collateral (identify source), UDS/breathalyzer with dates, PDMP review with date, standardized instruments with scores, medical record review]

Patient Attendance: [present / not present] (If not present, document outreach attempts with dates and whether review was completed without the patient.)

(Omit sections or bullets that are not applicable, except in Risk and Safety Update where absence of assessment must be explicitly noted with rationale. Distinguish patient-reported information from objective measures throughout. Do not infer abstinence status; state whether conclusions are based on patient report, objective testing, or both.)

Reason for Review and Patient Priorities

(Briefly state why this review is occurring, then document the patient's priorities and goals in their own words. Include at least one direct patient quote when it meaningfully anchors the plan.)

• Reason for review: [90-day scheduled review / triggered by: relapse, housing loss, hospitalization, legal event, medical change, patient request, other]
• What matters most to the patient now: [patient-stated priorities] (Include direct quote when available.)
• Preference-sensitive decisions: [harm reduction vs abstinence goals, modality or setting preferences, visit cadence preferences]
• Treatment priorities for next interval: [brief list of prioritized outcomes]

Active Diagnoses and Problem List

Last treatment plan date: [date] • Today's revisions: [concise summary of what is being revised] (State explicitly if unchanged since last review.)

• Substance use disorders: [diagnoses with severity and remission status]
• Psychiatric: [co-occurring psychiatric diagnoses and status]
• Medical: [conditions relevant to treatment such as chronic pain, pregnancy, hepatitis C]
• Other active problems: [legal, housing, employment, family] (Maintain consistent domain order across reviews.)

Interval Summary

(Provide a concise narrative of the review period emphasizing events affecting risk, medical necessity, and plan design. Separate patient report from objective data.)

[Interval narrative summary]

• Substance use pattern this interval: [frequency, quantity, route, changes vs last review] (Specify: patient report, objective testing, or both.)
• Cravings and withdrawal course: [summary]
• Overdose events or naloxone use: [dates and brief details]
• ED visits, hospitalizations, or acute episodes: [dates and reasons]
• Treatment engagement: [attendance, participation, response to interventions]
• Medications (MOUD/psychiatric): [adherence, tolerance, side effects, changes]
• Psychosocial changes: [housing, employment, family, legal updates]
• Recovery supports utilized: [mutual support groups, peer support, recovery housing]
• Protective factors and strengths: [list]
• Objective data: [UDS/breathalyzer results with dates, PDMP findings, standardized instrument scores with comparison to baseline]
• Data limitations: [key data unavailable and reason; how plan accounts for uncertainty]

Goal-by-Goal Progress

(For each active goal: state the problem/need, long-term goal, and SMART objectives. Assign status to each objective: Achieved, Improving, Unchanged, Worsening, Not Addressed, or Discontinued. Provide evidence, barriers, clinical interpretation, and decision.)

• [Goal 1: Long-term patient-centered goal]

  Problem/need statement: [concise statement linking need to risks/impairment]

  • Objectives:
    • [Objective A: SMART statement with metric, target, timeframe, data source] • Status: [Achieved / Improving / Unchanged / Worsening / Not Addressed / Discontinued]
      • Evidence — patient report: [brief]
      • Evidence — objective: [UDS/PDMP/instrument scores/attendance logs]
      • Barriers: [specific barriers for this objective]
      • Clinical interpretation: [brief rationale linking data to status]
      • Decision: [continue unchanged / revise objective / revise intervention / change frequency / discontinue] (If discontinuing: achieved, no longer relevant, patient declined, clinically inappropriate, or deferred.)
    • [Objective B: SMART statement] • Status: [status]
      • Evidence — patient report: [brief]
      • Evidence — objective: [brief]
      • Barriers: [brief]
      • Clinical interpretation: [brief]
      • Decision: [action]
  • Interventions delivered (for this goal): [modalities provided and patient response]
  • Recommendations declined: [what was recommended, patient's reason, risk discussion, harm-reduction alternative offered] (Include only if applicable.)
• (Repeat goal block for each additional active goal.)

Risk and Safety Update

(Must be explicit and current. If any domain was not assessed this interval, document the reason.)

• Overdose risk: [overdoses since last review, naloxone access, overdose education provided/updated, current risk drivers (polysubstance use, fentanyl exposure, using alone, recent return to use after abstinence), harm-reduction steps in plan]
• Suicide and self-harm risk: [ideation, intent, plan, means access, protective factors, safety plan status: updated/unchanged] (If not assessed, state rationale.)
• Withdrawal and medical risk: [withdrawal risk including seizure risk for alcohol/benzodiazepines, pregnancy considerations, acute medical issues, higher level of care considered with rationale and decision]
• Safeguarding/mandated reporting: [concerns and actions taken] (Include only if applicable; use minimal necessary detail.)

Barriers, Social Determinants, and Recovery Environment

(Document barriers with enough specificity to justify interventions and service intensity. If no new issues, state: no new barriers identified this interval.)

• Barriers: [housing stability, food insecurity, transportation/phone access, legal status/court obligations, employment/education, family/parenting, recovery environment risks such as substance use in home or partner use]
• Supports and Strengths: [supportive relationships, recovery housing, sponsor/peer support/mutual support groups, faith community, other protective factors]
• Plan response to barriers: [how interventions address identified barriers]

Level of Care and Service Intensity Review

• Current services: [groups per week, individual sessions per month, case management, peer support, MOUD regimen and monitoring cadence, other services]
• Decision: [continue current level / step up / step down / transfer / initiate discharge planning]
• Clinical rationale: [tie to risk changes, treatment response, engagement, recovery environment, barriers to transition]
• If recommending change: [why less intensive care is insufficient or more intensive care not necessary, expected benefit of change, time-limited goals for next interval]

Coordination of Care and Referrals

(Include when coordination occurred or is essential to plan feasibility. Omit section if not applicable.)

• Care coordination with: [primary care, psychiatry, pain management, OB, infectious disease, case management] — [dates and key outcomes]
• Referrals placed: [service or provider] — [scheduled / completed / barrier encountered] — [appointment date if available]
• Patient education delivered: [harm reduction, safer use, naloxone training, medication safety]
• Recommendations received and follow-through plan: [summary and next steps]

Updated Treatment Plan

Effective date: [date] • Next review: [target date or trigger conditions]

• [Goal 1: Long-term patient-centered goal]
  • SMART objectives:
    • [Objective A] — Target: [date]; Metric: [UDS/attendance/instrument score/self-report]
    • [Objective B] — Target: [date]; Metric: [details]
  • Interventions: [modality (individual/group/family/case management/peer support/medication management), frequency, anticipated duration, responsible party by role, location or telehealth/in-person]
  • Patient responsibilities: [what the patient agreed to do]
  • Patient-declined components: [recommendation, patient's reason, risk discussion, agreed alternative] (Include only if applicable.)
  • Safety/relapse prevention plan: [updated / unchanged] — [warning signs, coping strategies, emergency contacts, naloxone access]
• (Repeat for each additional active goal.)

Signatures

Clinician: [name, credentials, date]

Patient Signature/Attestation: [obtained / declined / unavailable] (If declined or unavailable, document attempt and reason.)

Supervisor Co-signature: [name, credentials, date] (Include only if required by program or payer.)