General Encounter Note: Provider Intake Template

Exam: 

The following is taken from my personal visual or audible examination of the patient via the video or telephone interface as well as the patients self-examination with guidance from me: 

General: Does not appear acutely ill 

Head: Normocephalic/atraumatic 

Ears: Symmetric and good hearing bilaterally 

Eyes: Sclera not injected 

Mouth: Lips do not appear to be swollen 

Neck: Full range of motion 

Lungs: Symmetric chest rise, does not appear to have labored breathing 

MSK: Moving upper extremities well bilaterally 

Skin: No rashes noted on face 

Psych: Appears to be in appropriate mood 

Assessment: 

Patient meets criteria for DSM5 disorder of substance use disorder: 
A problematic pattern of use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12-month period: 
-Often taken in larger amounts or over a longer period than was intended 
-A persistent desire or unsuccessful effort to cut down or control use 
-A great deal of time is spent in activities necessary to obtain, use, or recover from the substance’s effects 
-Cravings or a strong desire to urge to use the substance 
-Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home 
-Continue use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by its effects 
-Important social , occupational, or recreational activities are given up or reduced because of use 
– Recurrent use in situations in which it is physically hazardous 
-Continues use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by the substance 
-Tolerance 
-Withdrawal 

Plan: 

Will continue suboxone 8mg BID 

F/U in 1 month 

I have encouraged this patient to continue/initiate going to support group therapy as there is strong evidence for dual therapy with group therapy and pharmacotherapy in the management of OUD 
 
Patient was instructed to f/u with PCP/specialist for routine health care/medical issues/concerns  
 
I discussed the importance of strict compliance of our treatment plan, and to avoid other drug use especially benzodiazepines (unless prescribed) and alcohol as it may lead to overdose and potential death. Do not sell or share this medication.  

I have queried the prescription drug monitoring program website and have found no recent prescriptions for opioids, amphetamines, or benzodiazepines