Buprenorphine induction, methadone clinic, and naltrexone follow-up each have their own shape. All three need more than SOAP: counseling referral, UDS, withdrawal scoring at induction, and the adherence narrative that supports continued prescribing.
Built for addiction-medicine practices and psychiatrists who still document to that discipline after the X-waiver sunset. Covers buprenorphine induction and maintenance, oral naltrexone and Vivitrol, and methadone follow-up. COWS or CINA, UDS, counseling coordination, and DEA-facing controlled-substance fields are in the note, not a lab tab.
Patient: [patient_name] DOB: [dob] Age: [age]
Date: [encounter_date] Provider: [provider_name] Duration: [duration]
Substance use disorder diagnosis: [icd10]
MAT medication: buprenorphine / buprenorphine-naloxone / methadone / naltrexone (PO) / naltrexone (Vivitrol)
Phase: induction / stabilization / maintenance / taper
Subjective
- Last use date (alcohol, opioids, stimulants, benzodiazepines, cannabis, other):
- Cravings (frequency, intensity, triggers):
- Withdrawal symptoms since last visit:
- Adherence to MAT medication:
- Side effects:
- Counseling and behavioral-health engagement:
- Recovery support engagement (NA, AA, SMART, peer support):
- Stressors and recent life events:
- Legal, employment, family update:
Objective
- Vitals:
- COWS or CINA score (induction or as clinically indicated):
- Pinpoint pupils, diaphoresis, tremor, other physical findings:
- Mental status exam:
- UDS results (this visit and trend):
- Confirmatory testing if performed:
- PDMP review documented: yes / no
- Date of last PDMP query:
Risk assessment
- Overdose risk:
- Naloxone in home: yes / no
- Suicidal or self-harm ideation:
- Concurrent prescribed CNS depressants:
- Pregnancy status if applicable:
Assessment
- Treatment response (engagement, abstinence, harm reduction):
- Diagnostic clarification:
- Co-occurring psychiatric conditions:
- Risk and protective factors update:
Plan
- Medication continued (drug, dose, formulation):
- Dose adjustment (with rationale):
- Prescription written: days supply, refills, pharmacy:
- Counseling and behavioral-health referral status:
- Naloxone prescribed or refilled: yes / no
- UDS frequency for next interval:
- Labs (LFTs for naltrexone, hepatitis screening, HIV screening as indicated):
- Safety planning:
- Follow-up interval:
- Coordination with PCP, OB, criminal-justice supervision:AriaMD routes MAT data during the visit. COWS lands in the COWS field. UDS results tag to the visit and the trend. PDMP query confirmation is logged. Buprenorphine and naltrexone variants each pull their own field set. Regulatory paperwork stays in the same chart.