%AM, %375 %31 %2017 %00:%Jan

Buprenorphine Induction Visit

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S: Pt presents for bup induction. Pt feels to be in moderate w/d. Pt c/o cramps, sweats, chills, goose bumps, anxiety, and joint pains. Has not used anything since _

 

O:

Gen: Anxious and fidgety.

See VSS above

See scanned COWS sheet for details


A/P:

Induction:

- Dosing today (day 1): Please see scanned dosing record. End dose for today is _ mg to be used _. Pt may use 4 mg at night if they feel w/d sx.

 

Pt to f/u day 3 AM at _ to determine maintenance dose.

 

20 minutes spent in interviewing and counselling and discussing the plan and coordinating care.

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  • All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly fradulent.