• Patient Note

    Suboxone Follow Up
  • Note created on this date:
     - -
  • Vitals
  • Pregnancy (historical)*
  • Has the patient completed STI screening?*

  • Please complete the STI screener: Get STD Screener

  • If the patient is at an offsite sober living facility, you can schedule the patient for Rapid Hep C testing in the future by completing a referral form.  Go to the link: Schedule for Rapid Hep C

    Choose the facility that the patient is at and complete the form.

  • Surveillance Monitoring?*

  • This is a patient in active treatment for substance use disorder (SUD), and UDS/ UDT is a medically necessary and useful component of chemical dependency diagnosis and treatment, which influences treatment and level of care decisions. Monitoring is required to determine substances which can impact the treatment plan, interact with prescribed medications or taking prescribed medications as expected. For patients with a diagnosed SUD, the clinician should perform random UDT and at random intervals in order to properly monitor the patient.

    The frequency and the rational for UDS/UDT is on the following schedule:

    1) for patients meeting their compliance goals and attending the clinic on a monthly basis, UDS is at a frequency of 1 time/ month

    2) for patients not meeting their compliance goals and attending the clinic on a two times/ month basis, UDS is at a frequency of 2 times/ month

  • Did the patient have Rapid Hep C Screening today?*

  • PROBLEM #1: OPIOID USE DISORDER
    PROBLEM #2: CONCOMITANT USE OF ANOTHER HARMFUL OR ILLICIT SUBSTANCE
    PROBLEM #3: PSYCHIATRIC COMORBIDITY
    PROBLEM #4: SCREENING/ REFERRAL FOR SOCIAL SERVICES
    PROBLEM #5: ADDRESSING QUALITY OF LIFE ISSUES WITH PATIENT
    PROBLEM #6: SMOKING CESSATION

  • Cravings / Withdrawal / Taper:
  • Was a Screener done today?

  • LINKS TO SCREENERS

    • GAD-7 (anxiety)
    • PHQ9 (depression)
    • Smoking Cessation
    • AUDIT- C (alcohol)
    • I Need/ I Want
    • Pain Disability Index (PDI)
    • Quality of Life (QOL)
    • Social Determinants of Health (SDOH)
    • ADHD
    • Mood Disorder
    • Epworth Sleepiness Scale (ESS)
    • HARK
    • Opioid Induced Constipation (OIC)
    • CIWA - AR Screening
  • Administer Smoking Cessation Screener and then check the patient's preference:
  • Counseling*
  • Compliance/ the patient is compliant with:*

  • List Current Psych Meds and their Indication

  • Send your patients educational information about their psych meds!!  CLICK THIS LINK

  • General Appearance: Patient alert and oriented, appropriate mood and affect.
  • Psychiatric: Recent and remote memory is intact. Attention span, concentration, language, and fund of knowledge sufficient.
  • HEENT: Normocephalic. Pupils, conjunctivae, and mucous membranes normal. No cyanosis or icterus.
  • Neck: Supple without jugular venous distention. No masses noted with full range of motion. Trachea midline.
  • Respiratory: Regular rate without wheeze, non labored.
  • Cardiac: Regular, rate, rhythm.
  • Neurologic: No gross sensory or motor deficits. Cranial nerves II - XII intact.
  • Abdomen: No distension, no masses or organomegaly.
  • Musculoskeletal: Normal range of motion without pain or crepitus. No deformities or muscle wasting. Muscle strength 5 / 5.
  • Skin: Skin moist, well perfused.
  • Lymphatic: No lymphadenopathy.
  • Hep C Test Result*
  • Is Hep B blood testing recommended?*

  • COMPLIANCE

    There are 4 objective measures we use to quantify a patient's compliance with their treatment -- attendance, licit UDS, participation in counseling and proper use of their medication. 

  • The patient has earned the privilege to attend clinic appointments with the frequency of E-prescribing on the following basis:*

  • Compliance was stressed and the patient was counseled. Specifically, it was reinforced that the patient must attend the clinic on a regular basis, must provide licit UDS, and must attend counseling. If the patient can achieve these goals, then the patient will be seen on a less frequent basis.

  • The current phase is:*
  • Did the patient have an injection today?*
  • Did you ORDER an injectable or specialty medication from BrightStart or Lake Cumberland Pharmacy today for future administration?*

  • The patient has authorized BrightStart Pharmacy to bill insurance and deliver their medication to our office.

    The patient has an established relationship with SpecialistsMAT, which is a covered entity; the entity maintains records of the individual’s care. Today's care was rendered by a professional employed by SpecialistsMAT (the covered entity). Today's services that were rendered are consistent with the services for which grant funding has been provided to the entity.

  • What specialty medication did you order?*

  • If you are ordering a medication from BrightStart Pharmacy and that medication is going to be mailed to the patient, please confirm a current mailing address.  Click on the link:

    PATIENT ADDRESS

  • The patient is part of the "Fewer Clinic Visits" Program*.  The patient meets 3 criteria: 1) they agree to having a Sublocade or Brixadi (monthly) injections only; 2) they attend the clinic on a bi-monthly basis; 3) they are seen onsite in Jeffersontown / Elizabethtown or Russell County Hospital.  (*Note: patients from transitional living facilities and the Department of Corrections do NOT participate in this unique program.)  

    *Following today's appointment, please schedule the patient with the front desk to have a virtual appointment ("check in") in 2 weeks.  Next month's injection will be ordered at that visit.

  • Would you like to order a second medication from the BrightStart or Lake Cumberland Pharmacy? This would include patients placed on the Rapid Induction Protocol for Sublocade.*
  • What second specialty medication did you order?*

  • Can you confirm either the PRESCRIBING provider or the PATIENT are in Jeffersontown / Elizabethtown office (location)?*

  • _________________________________________________________

    Please make sure that either the patient or "ordering" provider is in the Jeffersontown office/ location.  If these criteria are not met, please contact a provider on site in Jeffersontown to briefly see the patient regarding the injection or specialty medication.  This individual will serve as the "ordering provider" for this encounter, and WILL ORDER THE INJECTION / SPECIALTY MEDICATION IN MDTOOL BOX. 

    You will remain as the "rendering" provider for today's service.  As the "rendering" provider, you will sign today's chart note as normal. 

  • Vivitrol/ naltrexone treatment

    This patient meets the DSM5 Criteria for Alcohol Use Disorder (AUD) / Opioid Use Disorder (OUD). Vivitrol contains naltrexone, an opioid antagonist, and is indicated for the treatment of alcohol dependence / OUD in patients who are able to abstain from alcohol / opiates in an outpatient setting prior to initiation of treatment with Vivitrol. Vivitrol should be part of a comprehensive management program that includes psychosocial support.

  • Prior to administering Vivitrol/ naltrexone please check the following:*

  • The patient's history, relevant prescription monitoring information (i.e., PDMP report), and UDS result was evaluated prior to sending the patient's e-prescription to the pharmacy.

  • Time based billing for E/ M codes represents total time spent by physician/qualified health care professional on the date of service. This includes time for chart review and time spent writing the patient note. Eligible time includes both the face-to-face and non-face-to-face time that the qualified health provider personally spends before, during and after the visit on that same day.

     

    99213 = 20 -29 minutes
    99214= 30-39 minutes
    99215 = 40-54 minutes

  • Primary Billing/ E-M Code*
  • Primary CPT/ ICD 10/ DIAGNOSIS codes*

  • If the patient's chief complaint is equal to the following: 

    • Pyschiatric / Behavioral Consult

    • Palliative Care Consult

    • Pain Management Consult

    • Other

    Then choose from the lists of CPT/ ICD 10/ Diagnosis codes below. 

  • Would you like to see ADJUNCT CPT/ ICD 10 Codes for MAT?*
  • ADJUNCT CPT/ ICD 10 Codes for MAT
  • Would you like to see ADJUNCT CPT/ ICD 10 Codes for PSYCH?*
  • PSCYH CPT/ ICD 10 Codes

  • Go to ICD10Data.com: LINK

  • Are there any additional CPT/ ICD 10 Codes you would like to add?
  • Was this visit part of the Russell County Hospital health initiative?*
  • Where was the patient located?*
  • Which office is the patient sitting in?*
  • Which office is the provider sitting in?*
  • Is the patient a resident with any of these sober living/ recovery facilities?*
  • Is the patient a participant in Recovery NOW's Therapeutic Rehabilitation Program (TRP)?*
  • Choose the patient's next appointment date*
     - -

  • As the providing practitioner, I spent * minutes seeing this patient today and documenting the encounter. I spent time reviewing and discussing with the patient the patient's compliance with treatment including their attendance history with the clinic and with counseling, their UDS history and results, and their UDT (quantitative testing) results if indicated. I did review the recent KASPER report. I have coordinated care with either the counseling team or the case management team. Additional screenings and interventions are noted in the history and assessment and plan as above. Medications were written following review of the KASPER report.

  • Today's rendering provider is:   *    field. Today's prescribing provider is:   *   .

  • As the rendering provider, I discussed today's appointment and care of the patient with the prescribing provider, who was responsible for ordering the patient's scheduled/ controlled medication with the pharmacy.

    The patient has an established relationship with SpecialistsMAT, which is a covered entity; the entity maintains records of the individual’s care. Today's care was rendered by a professional employed by SpecialistsMAT (the covered entity). Today's services that were rendered are consistent with the services for which grant funding has been provided to the entity.

  • DATE OF SERVICE*
     - -

  • Today's rendering provider was Erika Ruth, MD, and the supervising provider for this service was Leslie Dally, DO.

  • As the supervising and billing provider, I was the consulting physician during the evaluation of this patient on this date of service. I approve the treatment plan.

  • Today's provider was {provider}.  If you have questions regarding the services rendered by this provider, you can contact the provider via email at: {providerEmail}.

    When emailing our providers please be cognizant of HIPAA Guidelines; do not use personal health information or personal identifiers in your email.  We recommend that you identify your patient by copying and pasting the patient's MRN into the email: {chart52}.

    Within your email, please provide a phone number for our providers to address your concerns.

      

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