Psychiatry
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Opioid use disorder. Patient desires medication assisted treatment with
buprenorphine/naloxone. Understands the benefits and risks. Here today for follow-up
appointment after suboxone induction on [date name="variable_1" default="11/24/2020"].
 Reviewed Opisafe patient reported measures. Depression score [text name="variable_1" default="/20"] GAD/Anxiety [text name="variable_1" default="/7"] / Quality of Life__________ / Pain/function__________
 Now in stabilization / maintenance phase of treatment.
 Today, no signs of withdrawal. COWS = [text name="variable_1" default="0"]
 Patient reports side effects of: [select name="variable_1" value="none|constipation|headache"]
 Cravings: [select name="variable_1" value="none|few|often"]
 Current dose: [text name="variable_1" default="mg"]
 Last fill: [date name="variable_1" default="11/24/2020"]
 Pill/film count: [text name="variable_1" default="pills/films"]
 PDMP/OpiSafe Check: [text name="variable_1" default="no unexpected info"]
 Last UDT date and results: [date name="variable_1" default="11/24/2020"] [text name="variable_1" default="as expected"]

Doing [select name="variable_1" value="well|very well|not so well"] with treatment. Is participating in counseling and I stressed the critical importance of counseling and behavioral health care in addition to MAT.
Patient voiced understanding and willingness to participate fully in treatment. No
evidence of drug diversion. No relapse with continued interest in continuing
buprenorphine MAT program.
 Patient instructed in proper use of medication and long-term treatment per practice protocol.
 Naloxone education and training provided to patient to decrease overdose risk.
 We will check in with him/her weekly. Precautions discussed. Call or return if worse symptoms, withdrawal, or cravings.
Discussed potential side effects and their management. Osmotic stool softener for
constipation. (Miralax)
 Continue suboxone SL total daily dose of [text name="variable_1" default="mg"], Scripts written.
 Appointment in [text name="variable_1" default="1"] weeks for recheck and refills. Continue full MAT program through the practice with counseling, support, random UAs, etc.
 UA today for buprenorphine and opioid drugs of abuse.
Opioid use disorder. Patient desires medication assisted treatment with
buprenorphine/naloxone. Understands the benefits and risks. Here today for follow-up
appointment after suboxone induction on .
 Reviewed Opisafe patient reported measures. Depression score GAD/Anxiety / Quality of Life__________ / Pain/function__________
 Now in stabilization / maintenance phase of treatment.
 Today, no signs of withdrawal. COWS =
 Patient reports side effects of:
 Cravings:
 Current dose:
 Last fill:
 Pill/film count:
 PDMP/OpiSafe Check:
 Last UDT date and results:

Doing with treatment. Is participating in counseling and I stressed the critical importance of counseling and behavioral health care in addition to MAT.
Patient voiced understanding and willingness to participate fully in treatment. No
evidence of drug diversion. No relapse with continued interest in continuing
buprenorphine MAT program.
 Patient instructed in proper use of medication and long-term treatment per practice protocol.
 Naloxone education and training provided to patient to decrease overdose risk.
 We will check in with him/her weekly. Precautions discussed. Call or return if worse symptoms, withdrawal, or cravings.
Discussed potential side effects and their management. Osmotic stool softener for
constipation. (Miralax)
 Continue suboxone SL total daily dose of , Scripts written.
 Appointment in weeks for recheck and refills. Continue full MAT program through the practice with counseling, support, random UAs, etc.
 UA today for buprenorphine and opioid drugs of abuse.

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