Withdrawal Management Admission Note (Alcohol, Opioid, or Sedative)

Date/Time: [date and time of admission]  |  Location/Service: [ED / inpatient medical / residential withdrawal management / ICU / other]  |  Primary Substance(s): [alcohol / opioids / sedative-hypnotics / polysubstance]  |  History Source/Reliability: [patient / collateral / chart / EMS] — [reliability limitations if any: intoxication / delirium / language barrier / cognitive impairment / poor historian / none]

Chief Concern

[Patient-stated concern in quotes if available] — [Brief clinical translation, e.g., "Admission for medically managed alcohol withdrawal"]

Immediate Safety Screen

• Mental status: [orientation / confusion / agitation / sedation]
• Immediate safety risks: Suicidal ideation [yes/no/unknown]; violence/elopement risk [yes/no/unknown]; ability to self-care [intact/impaired/unknown]
• Severe intoxication/respiratory depression: [present/absent] (Include RR, SpO2, pupil size, level of consciousness if concerning.)
• Pregnancy status: [pregnant / not pregnant / unknown] (Include LMP or gestational age if applicable.)

History of Present Illness

[Narrative of presentation circumstances and current withdrawal symptoms by domain: autonomic (diaphoresis, tremor, tachycardia, hypertension), neuropsychiatric (anxiety, agitation, hallucinations, confusion), GI (nausea, vomiting, diarrhea), opioid-specific (myalgias, rhinorrhea, piloerection, restlessness), sedative-specific (rebound anxiety, insomnia, perceptual disturbances). Include pre-hospital or ED medications given with doses and times.] (1–3 paragraphs.)

Substance Timeline: (Include only implicated substances. If screened and not involved, use single line: "[Substance]: Screened, not suspected.")

• Alcohol:
  • Last drink: [date/time] or [unknown—reason]
  • Typical daily amount: [volume, type, standard drinks/day]
  • Duration of current pattern: [duration]
  • Recent escalation/triggers: [details if present]
• Opioids:
  • Last use: [date/time] or [unknown—reason]; type/route: [substance and route]
  • Typical daily amount and frequency: [details]
  • Duration of current pattern: [duration]
  • Recent escalation/triggers: [details if present]
• Sedative-hypnotics:
  • Last use: [date/time] or [unknown—reason]; agent(s): [name, dose, route]
  • Typical daily dose and frequency: [details]; prescriber: [if known]
  • Duration of current pattern: [duration]
  • Recent changes/abrupt discontinuation: [details if present]

Prior Complicated Withdrawal History: (Document yes/no/unknown with details for each.)

• Alcohol: Prior withdrawal seizures [yes/no/unknown]; delirium tremens [yes/no/unknown]; ICU admission or intubation [yes/no/unknown]
• Opioids: Overdose history [yes/no/unknown—count if known]; naloxone reversals [yes/no/unknown]; precipitated withdrawal [yes/no/unknown]; prior MOUD trials [agent(s) and response]
• Sedative-hypnotics: Prior withdrawal seizures or delirium [yes/no/unknown]; high-dose or prolonged use [yes/no/unknown]; abrupt discontinuation episodes [yes/no/unknown]

Prior Treatment History: [Previous detox admissions, protocols used, complications; current/prior MOUD with dose and verification status; prior AUD pharmacotherapy; prior sedative taper attempts and outcomes]

Risk Stratification Summary: [2–4 sentences synthesizing: current withdrawal severity based on scores and exam; risk of progression given history and comorbidities; planned monitoring level and rationale; any limitations to standard scoring and alternative strategy if applicable]

Past Medical and Psychiatric History

• Neurologic: [seizure disorder / TBI / stroke / none]
• Hepatic/GI: [cirrhosis / hepatitis / pancreatitis / GI bleeding / none]
• Cardiac: [CAD / heart failure / arrhythmia / QT prolongation risk / none]
• Respiratory: [COPD / OSA / hypoventilation risk / none]
• Infectious: [HIV / HCV / endocarditis history / recurrent SSTI / none]
• Psychiatric: [diagnoses]; prior suicide attempts [yes/no/unknown]
• Pregnancy: [pregnant with gestational age / not pregnant / unknown]
• Other relevant conditions: [conditions affecting medication selection]

Medications and Allergies

Current medications: [list with doses] (Emphasize MOUD with verification status, benzodiazepines/sedatives with prescriber, anticonvulsants, antipsychotics, beta-blockers.)

Adherence: [adherent / partial / non-adherent / unknown]

Allergies: [agent and reaction type] (Distinguish true allergy from expected side effects for opioids and benzodiazepines.)

Social History

• Housing: [stable / unstable / shelter / unsheltered]; safe medication storage [yes/no/unknown]
• Support system: [caregiver availability and contact]
• Follow-up feasibility: [transportation, phone access]
• Home safety: [children, firearms, IPV if relevant]
• Injection practices: [details if applicable]; wound/abscess history [yes/no]

Review of Systems

[Targeted ROS: neurologic (seizure, syncope), psychiatric (hallucinations, suicidal ideation), GI, cardiopulmonary, infectious symptoms if injection use or fever present] (Include only pertinent positives and negatives actually reviewed.)

Physical Examination

Vital signs: [BP, HR, RR, Temp, SpO2 with timestamp]; pain [score]; weight [if obtained]

• General: [appearance, distress, diaphoresis, tremor, psychomotor activity]
• HEENT: [pupil size/reactivity, mucous membranes, nystagmus]
• Cardiovascular: [rate, rhythm, murmurs]
• Respiratory: [work of breathing, breath sounds, aspiration risk]
• Abdomen: [tenderness, distension, organomegaly]
• Neurologic: [orientation, attention, tremor, asterixis, gait, focal deficits]
• Skin: [track marks, cellulitis, abscesses, jaundice]
• Mental status: [appearance, mood/affect, thought process, perceptual disturbances, SI/HI, insight/judgment, capacity]

Withdrawal Assessment and Scoring

• Alcohol (CIWA-Ar): Score [value] at [time]; peak [value] at [time] — [mild/moderate/severe]. Reassessment frequency: [q1-4h]. Validity: [valid / limited by delirium or cognitive impairment—alternative monitoring strategy if limited]
• Opioids (COWS): Score [value] at [time] — [mild/moderate/severe]. Objective signs for buprenorphine readiness: [findings if applicable]. Validity: [valid / limited—alternative if applicable]
• Sedative-hypnotics: [Scale and score if used locally] or [structured clinical features: anxiety, tremor, insomnia, perceptual changes, seizure risk]. Validity and monitoring plan: [details]

Diagnostics

• CBC: [results and interpretation]
• CMP with Mg/Phos, LFTs: [results and interpretation]
• Glucose: [value]
• Ethanol level: [value and time] (Interpret relative to last use timeline.)
• Urine toxicology: [results] (Note limitations: fentanyl coverage, timing, false positives/negatives.)
• Pregnancy test: [result if applicable]
• ECG: [rate, rhythm, QTc] (If indicated.)
• Infectious screening: [HIV/HCV/other results if indicated]
• Other: [additional relevant studies]

Assessment

1. [Primary withdrawal diagnosis]: [severity and evidence from history, exam, scores, labs]. Differential considerations: [infection, hypoglycemia, hepatic encephalopathy, head injury, medication toxicity]. Risk factors: [prior complicated withdrawal, polysubstance, trajectory].
2. [Additional withdrawal or substance-related problems if present]: [evidence and severity]
3. [Comorbid medical/psychiatric conditions affecting management]: [brief assessment]
4. [Social and safety considerations]: [brief assessment]

Plan

(Include only applicable substance-specific sections.)

Alcohol Withdrawal Management

• Pharmacotherapy: [symptom-triggered / fixed-schedule / front-loading] with [agent, dose, parameters]
• Supportive care: Thiamine [dose, route, frequency]; electrolyte repletion [Mg/K/Phos]; fluids; nutrition
• Monitoring: Vitals q[frequency]; CIWA-Ar q[frequency]; continuous pulse oximetry [yes/no]; seizure and fall precautions
• Escalation criteria: [worsening despite max dosing, seizures, suspected DTs, hemodynamic instability] → [higher level of care]; seizure and delirium protocols [reference or outline]

Opioid Withdrawal Management

• Treatment intent: [symptom management only / MOUD initiation]
• Buprenorphine induction: Initiate when COWS ≥[threshold]; last full agonist [time]; initial dose [mg]; redosing plan. (If high-potency fentanyl exposure: [micro-induction / standard induction] with rationale.)
• Methadone: [dose] with [QTc monitoring, sedation checks, respiratory monitoring]; OTP coordination for continuation (If used.)
• Adjunctive medications: [clonidine, NSAIDs, antiemetics, antidiarrheals, sleep aids as indicated]
• Naloxone: Provide kit and education prior to discharge

Sedative-Hypnotic Withdrawal Management

• Strategy: [continue home agent / convert to longer-acting agent] — abrupt discontinuation contraindicated
• Taper plan: Initial equivalent dose [mg]; taper rate [percentage per interval]; hold parameters [oversedation, hypotension, ataxia]
• Monitoring: Vitals q[frequency]; sedation scale; respiratory monitoring; seizure and fall precautions
• Escalation criteria: [seizure, delirium, refractory symptoms, respiratory depression] → higher level of care

Polysubstance Considerations

(Include if ≥2 CNS depressants involved.)

• Over-sedation mitigation: [stagger sedating medications, use lowest effective doses, avoid co-administration]
• Enhanced monitoring: [continuous oximetry / capnography / sitter] as indicated
• Coordination: [clear dosing ownership, daily sedation burden review]

Substance Use Disorder Treatment

• Diagnoses: [AUD / OUD / sedative use disorder with severity]
• Patient goals: [stated goals]
• Consults: [Addiction Medicine / social work / peer support]
• Pharmacotherapy plan: [MOUD continuation, AUD medications, taper plan]
• Linkage: [OTP / outpatient prescriber / counseling / residential] with warm handoff; appointment [date/time if scheduled]

Psychiatric and Safety Planning

(Include if relevant.)

• Suicide risk: [risk level, protective factors]; observation level [standard / enhanced / 1:1]; means safety
• Capacity: [intact / impaired—basis and plan]
• Agitation management: [de-escalation, environmental modifications, least-restrictive medications]

Disposition

• Discharge criteria: [stable scores, stable vitals, taper plan established, education completed, follow-up arranged]
• Follow-up: [appointments, OTP verification, pharmacy coordination]
• Harm reduction: [overdose prevention, naloxone, safer use practices, return precautions]

(If essential information is unavailable, use explicit placeholder with reason, e.g., "Last drink: [unknown—patient delirious, collateral pending]." Do not infer quantities or times without stating uncertainty. Include substance-specific sections only when that substance is involved.)