Withdrawal Management Daily Progress Note

Date/Time: [Date and time of note entry]

Provider: [Clinician name and role]

Care Setting: [inpatient / residential / ED observation / other]

Withdrawal Day #: [Day number and reference point (since last use / since admission)]

Substance(s): [Primary substance(s) undergoing withdrawal]

Protocol/Scale: [Monitoring protocol with scale and frequency]

Precautions: [seizure / fall / elopement / aspiration / none]

Interval Summary

[4–8 line narrative covering the last 24 hours] (Include: explicit trajectory [improving / stable / worsening] anchored to objective data; peak and most recent withdrawal scores with timestamps; total PRN doses administered with medication names; any complications or near-misses such as seizures, delirium, oversedation, falls; and headline plan for today. If scores were missed or unreliable, state why and what alternative assessment was used. Do not claim improvement or worsening without objective support.)

Subjective

Withdrawal symptoms: [Patient-reported symptoms by domain—autonomic, neurological, GI, sleep, perceptual—with change since yesterday] (If patient cannot participate due to delirium or somnolence, state this and note reliance on nursing observations.)

Medication experience: [Perceived benefit, side effects, refusals with reasons]

Safety screen: Suicidal ideation [present / absent / unable to assess] (If unable to assess, state reason.)

Engagement & preferences: [Patient engagement in care and disposition preferences]

Objective

Vitals: [Most recent vitals with time; note significant trends] (Include T, HR, BP, RR, SpO2 as relevant.)

Withdrawal Scores: [Scale name] — Most recent: [score @ time] ; Peak: [score @ time] ; Interpretation: [below / at / above medication threshold] (Note if scores missed or validity questionable; describe alternative assessment if used.)

Medications (Last 24h): [Scheduled withdrawal meds with doses and changes today] ; [PRNs: totals by agent, indication, response] (For sedatives, include sedation level and respiratory observations.)

Exam/MSE: [General appearance, tremor, orientation, psychomotor status, affect, thought content including hallucinations, cognition/attention, pertinent negatives] (If full exam not performed, state reason.)

Data: [Only actionable labs/toxicology/imaging affecting today's management]

Assessment

[1–2 paragraphs synthesizing current withdrawal syndrome and trajectory with objective evidence] (Explicitly address: presence or absence of complicated withdrawal including delirium and seizures; medication adverse effects including oversedation or respiratory concerns; medical mimics if relevant such as infection, metabolic derangement, head injury.)

Active Problems (ordered by acuity):

1. [Primary withdrawal syndrome with substance/scale]
2. [Co-occurring withdrawal, if present]
3. [Substance use disorder and treatment engagement]
4. [Psychiatric comorbidity and safety risk]
5. [Active medical issues]

(List only problems active today.)

Plan

[Problem 1]

Status: [Current score(s), vitals, exam findings]

Plan: [Management steps—medication adjustments, supportive care, consults]

Monitoring/escalation: [Frequency, thresholds for additional medication or higher level of care]

(For alcohol withdrawal: specify symptom-triggered vs taper strategy; thiamine route/dose; escalation criteria for delirium or seizure. For opioid withdrawal/OUD: document MOUD status; if initiating buprenorphine include time since last opioid, COWS score, response; naloxone provision plan. For sedative-hypnotic withdrawal: risk level, taper strategy, seizure precautions.)

[Additional Problems]

(Repeat status/plan/monitoring format for each active problem.)

Disposition & Aftercare

Medical readiness: [Anticipated date and criteria for step-down/discharge]

Warm handoff actions: [Referrals, appointments, coordination completed today]

Barriers: [Housing, transport, insurance, motivation]

Harm reduction: [Naloxone, safer use education, linkage to services]

Care Coordination & Education

[Nursing, social work, consults, family contacts and outcomes; education topics discussed and patient understanding] (Include only if coordination or education occurred today.)

(Omit sections that do not apply. When clinically important information is missing, document what is missing, why, and what action was taken.)