Open a MAT follow-up with last use and cravings, read the UDS and write what you will do about it, document the naloxone offer and whether a kit is in the home, then close the dose, counseling, and next toxicology. Intake fields, OTP take-homes, and Part 2 handling are in MAT note requirements 2026. This page is the per-visit loop.
Open with last use and current cravings
Substances, last date of use for each, route, and whether that is self-report only. Opioids, benzodiazepines, alcohol, stimulants, cannabis. “No issues” is not last use.
Cravings: frequency, intensity, triggers this interval. Withdrawal: if you score COWS, put the number in a COWS field, not a buried HPI clause. Adherence to the MAT medicine: missed strips, missed injection date, take-home methadone issues if you are documenting an OTP follow-up.
Functional status in a few domains (housing, work, legal) so the visit is not only a UDS argument.
If they overdosed since last visit, that is the first sentence, plus whether they were reversed with naloxone, and by whom.
Record the UDS result and your response
Result, date, expected positives (buprenorphine, norbuprenorphine), unexpected positives, unexpected negatives.
An unexpected result is a clinical fork. Write the fork:
- Unexpected negative buprenorphine: discuss diversion vs running out vs lab cutoff; consider a confirmatory test; consider more frequent visits or observed dosing; do not silently refill 30 days.
- Unexpected positive opioid: harm-reduction talk, possible dose review, tighter UDS, whether induction needs to be redone if they have been off.
- Unexpected benzo: PDMP, other prescribers, taper vs coordinated prescribing; overdose risk with buprenorphine is not zero when stacked.
- Cannabis-only positive in a stable patient: say whether that changes anything in your program. Silence plus a 90-day refill looks like you did not look.
PDMP query date belongs next to the UDS. Inconsistent stories (UDS vs report vs PDMP) go in Assessment as inconsistency, plus the action.
Document the naloxone offer and whether it is in the home
Every opioid-use-disorder visit, and any visit with overdose risk (return to use, dose interruption, benzodiazepines, new stimulant use): naloxone.
Not “naloxone discussed.” Kit in the home, expiration, who was trained (partner, roommate), whether you prescribed or refilled today, and whether they declined. A decline still gets a sentence and a re-offer next visit.
If they used naloxone on someone else, chart that. It is both clinical and a reason to replace the kit.
Counsel that naltrexone loss of tolerance raises overdose risk when the injection window lapses. That sentence belongs on XR-naltrexone follow-ups even when the UDS is clean.
Close the plan for dose, counseling, and next UDS
Medicine, dose, days supply or next injection date. Counseling or peer support: attended, referred, declined. Next UDS interval (sooner if the fork above was noisy). Follow-up date.
Part 2: you do not thin this note. You handle it. See privacy and 42 CFR Part 2.
Sample follow-up sequence
Last use: last fentanyl 2026-06-02 (patient). Alcohol none. Benzo none.
Cravings 2/10, evenings. Buprenorphine-naloxone 16/4 mg daily, no missed
doses. COWS 0.
UDS today: +buprenorphine, +norbuprenorphine, +THC; negative fentanyl,
oxy, benzo, amphetamine. PDMP 8/31/2026: this Rx only.
Response: THC unchanged from last three visits; no change in take-home
interval. Norbuprenorphine present; no diversion concern today.
Naloxone: two 4 mg nasal kits at home, exp 2027-01, partner trained.
No refill today. Re-offered; patient accepted remaining kits.
Plan: continue 16/4 mg, #14, 0 refills. Counseling: still weekly with
[name]. Next UDS at visit in 2 weeks. Call for any return to fentanyl.Questions people ask
If UDS is dirty, do I have to stop buprenorphine? No. Stopping is how people die. You have to respond in the chart: tighter follow-up, confirmation, higher level of care, or a different formulation. Silence is the error.
Is a home test as good as a lab immunoassay? Chart which you used. Confirm unexpected results when the decision is high-stakes (administrative discharge, report to a court). Courts and employers are not the same as your clinical UDS policy; do not mix those purposes without a Part 2-compliant release.