Psychiatry
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 28 views since views were countable.
Patient is a [text name="variable_1" default="sample text"] yrs. old,
[select name="variable_1" value="male|female|other"] who presents today for MAT. Patient started on opioids [text name="variable_1" default="sample text"]ago. Has been using opioids for [text name="variable_1" default="sample text"] years. Patient stated (s)he uses around [text name="variable_1" default="sample text"] per day. Patient [select name="variable_1" value="does|does not|N/A"]admit to using heroin [text name="variable_1" default="sample text"]times. Here with his/her
[text name="variable_1" default="sample text"]. Desires to get off opioids because:
[textarea name="variable_1" default="sample text"]

Patient applied for Medication Assisted Treatment (MAT) and the [clinic] MAT Team
reviewed and approved patient for MAT. Patient has agreed to participate in all aspects of treatment plan including follow-up appointments, counseling, group visits, urine drug testing, and other requirements as noted in the treatment protocol and patient agreement.
 Last opioids [text name="variable_1" default="sample text"] hours ago of
[select name="variable_1" value="short-acting|long-acting|unsure"] opioid.
 Today, patient feels pretty lousy. Anxious, slight abdominal pain.
 Patient has [select name="variable_1" value="good|limited|unsure"] social supports with family, neighbors, and friends.
Specifically, patient will have support from [text name="variable_1" default="sample text"]

Opioid Use Disorder Criteria. Mark all that apply to this patient. Include in HPI.

Opioids are often taken in larger amounts or over a longer period of time than
intended.
 There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
 A great deal of time is spent in activities necessary to obtain the opioid, use the
opioid, or recover from its effects.
 Craving, or a strong desire to use opioids.
 Recurrent opioid use resulting in failure to fulfill major role obligations at work, school
or home.
 Continued opioid use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of opioids.
 Important social, occupational or recreational activities are given up or reduced
because of opioid use.
 Recurrent opioid use in situations in which it is physically hazardous
 Continued use despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by opioids.
 *Tolerance, as defined by either of the following:
o a need for markedly increased amounts of opioids to achieve intoxication or
desired effect
o markedly diminished effect with continued use of the same amount of an
opioid
 *Withdrawal, as manifested by either of the following: the characteristic opioid
withdrawal syndrome, the same (or a closely related) substance are taken to relieve
or avoid withdrawal symptoms
Patient is a yrs. old,
who presents today for MAT. Patient started on opioids ago. Has been using opioids for years. Patient stated (s)he uses around per day. Patient admit to using heroin times. Here with his/her
. Desires to get off opioids because:


Patient applied for Medication Assisted Treatment (MAT) and the [clinic] MAT Team
reviewed and approved patient for MAT. Patient has agreed to participate in all aspects of treatment plan including follow-up appointments, counseling, group visits, urine drug testing, and other requirements as noted in the treatment protocol and patient agreement.
 Last opioids hours ago of
opioid.
 Today, patient feels pretty lousy. Anxious, slight abdominal pain.
 Patient has social supports with family, neighbors, and friends.
Specifically, patient will have support from

Opioid Use Disorder Criteria. Mark all that apply to this patient. Include in HPI.

Opioids are often taken in larger amounts or over a longer period of time than
intended.
 There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
 A great deal of time is spent in activities necessary to obtain the opioid, use the
opioid, or recover from its effects.
 Craving, or a strong desire to use opioids.
 Recurrent opioid use resulting in failure to fulfill major role obligations at work, school
or home.
 Continued opioid use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of opioids.
 Important social, occupational or recreational activities are given up or reduced
because of opioid use.
 Recurrent opioid use in situations in which it is physically hazardous
 Continued use despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by opioids.
 *Tolerance, as defined by either of the following:
o a need for markedly increased amounts of opioids to achieve intoxication or
desired effect
o markedly diminished effect with continued use of the same amount of an
opioid
 *Withdrawal, as manifested by either of the following: the characteristic opioid
withdrawal syndrome, the same (or a closely related) substance are taken to relieve
or avoid withdrawal symptoms

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: