• Patient Note

    Primary Medicine
  • Note created on this date:
     - -
  • Has the patient ever been seen by a SpecialistsMAT provider?*
  • Is this the patient's 1st Primary Care Medicine appointment?*
  • Vitals
  • History of current PREGNANCY?*
  • 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, UDS is at a frequency of 2 times/ month

  • UDS / UDT is done during patient appointments, which are scheduled at 14 and 28 days. This prevents overuse of resources. Furthermore, the practice outsources its urine drug testing, and we are not able to consistently achieve turn around times on this process of less than 10 days. Thus, if a patient returns to the clinic in less than 14 days, there is a high likelihood that there will be no new information available to evaluate.

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

  • List Current Psych Meds and their Indication

  • PROBLEM #1: Primary Care
    PROBLEM #2: Primary Care
    PROBLEM #3: Primary Care
    PROBLEM #4: Psychiatric Comorbidity
    PROBLEM #5: Opioid Use Disorder

  • Past Medical History

  • Check all that apply / PMH*
  • The patient uses following illicit substances*
  • Was a CIWA-AR Screening done today?

  • CIWA-AR Screening

    The Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-AR) is an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal. The CIWA-AR allows medical providers to measure the severity of patients' alcohol withdrawal syndrome.  You get the CIWA Screener at this link: LINK

  • IV Drug Use*

  • Infectious Disease

  • HEP C*
  • HIV*

  • Psychiatric History

  • Check all that apply /Psych*

  • Social History

  • Employment*
  • Legal issues*
  • Children*
  • 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:
  • 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.
  • Labs to Order
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  • Hep C Test Result*
  • Is Hep B blood testing recommended?*
  • The patient will attend clinic appointments with the frequency of E-prescribing on the following basis:*

  • 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.

  • 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

  • Can you confirm either the ORDERING 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 or Elizabethtown location.  If these criteria are not met, please contact a provider on site in Jeffersontown or Elizabethtown 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.

  • Primary Billing/ E-M Code (New Patient)*
  • Primary Billing/ E-M Code (Previously Seen)*
  • Would you like to see CPT/ ICD 10 Codes for MAT?*
  • CPT/ ICD 10 Codes for MAT
  • Would you like to see CPT/ ICD 10 Codes for Primary Care Medicine?*
  • CPT/ ICD 10 Codes for Primary Care Medicine
  • Would you like to see CPT/ ICD 10 Codes for PSYCH?*
  • PSYCH CPT/ ICD 10 Codes
  • Are there any additional CPT/ ICD 10 Codes you would like to add?*

  • Go to ICD10Data.com: LINK

  • Was this visit part of the Russell County Hospital health initiative?*
  • Where is the patient sitting?*
  • Where is the provider sitting?*
  • Is the patient a resident with any of these sober living/ recovery facilities?*
  • DATE OF SERVICE*
     - -

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

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

  • 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.

  • COMPLIANCE / general

    I reinforced the necessity of compliance with treatment agreements. This includes not sharing or selling/ trafficking of medications, not receiving opioid prescriptions from other physicians/ practitioners and not taking controlled substance medications for purposes other than those which they are prescribed. This also included participation in routine and/or random urine drug screens, as well as random pill counts, to monitor for compliance with treatment. The patient expressed understanding and acceptance of this information. The patient also understands and accepts that suspected non-compliance may be grounds for dismissal and discontinuation of care at the discretion of the treating physician/ practitioner.

  • COMPLIANCE / timing of appointments

    Compliance with treatment is outlined in this document:  Practice Guideline: Patient Compliance with Treatment.  In addition, our practice will follow the guidelines set forth by SAMHSA in the Treament Improvement Protocol (TIP), Series 63.  More specifically, patients in our practice are on an every 14 day schedule when treatment is initiated (i.e., a new patient) or when a patient returns to the clinic after a prolonged absence.  The medical necessity and professional determination for this is as follows:


    1) The practice outsources its urine drug testing, and we are not able to consistently achieve turn around times on this process of less than 10 days.  Thus, if a patient returns to the clinic in less than 14 days, there is a high likelihood that there will be no new information available to evaluate. 

    2) Transportation is our single most important barrier to treatment, and this is particularly true in the many non-urban areas that the practice services.  Of note, transportation, work and child care are acknowledged in the TIP, Series 63 as patient barriers, and these barriers should be considered when scheduling appointments.  While mindful of the importance of vigilance monitoring during the initial treatment phase, too many appointments are a hurdle to successful treatment. 

    3) The practice is not aware of any medical literature that increasing the frequency of appointments upon initiation of treatment is beneficial or improves outcomes with treatment.  However, all providers have the discretion to bring patients in for more appointments if medically indicated.

     

  • 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 HIPPA 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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