Resource Center: Experienced prescriber, Printable form/checklist

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Assessment and Screening Instruments
Description: 
This document provides a comprehensive collection of screening instruments and withdrawal assessments.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Commonly Used CPT Codes – Primary Care (PDF)
Description: 
PDF of Commonly Used CPT Codes in Primary Care
Source: 
Clinical Tools, Inc.
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Sample Consent Form

Description: 
This is a sample of a consent form that can be used when initiating buprenorphine treatment for a new patient.

BUPRENORPHINE MAINTENANCE TREATMENT

Sample #1 --Patient information and consent to treatment with buprenorphine

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Nursing Follow-up Visit
Description: 
This form can be used by nurses to note the areas that should be covered during a follow-up visit for patients on buprenorphine treatment.
Source: 
Colleen LaBelle, RN/Boston Medical Center
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Intake Questionnaire for treatment planning of a new patient
Description: 
This patient questionnaire from the California Society of Addiction Medicine (CSAM) is useful when beginning a new patient on buprenorphine maintenance treatment.
Source: 
California Society of Addiction Medicine (CSAM)
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Clinical Opioid Withdrawal Scale (COWS)
Description: 
This PDF Document contains the Clinical Opioid Withdrawal Scale (COWS), a common instrument used to assess a patient's opioid withdrawal severity.
Source: 
California Society of Addiction Medicine (CSAM)
3.6
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Objective Opiate Withdrawal Scale
Description: 
A checklist that allows the physician to determine if the patient is in withdrawal in order to administer initial buprenorphine dose.
Source: 
American Academy of Addiction Psychiatry (AAAP)
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Consent for Release of Information
Description: 
This form serves as a sample consent for release of the patient's information (type of information to be specified by the patient and/or doctor).
Source: 
American Academy of Addiction Psychiatry (AAAP)
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Drug Accountability Record
Description: 
This form helps clinics keep a record of the drugs given out to each patient. This particular form has sections for date, patient's name, patient ID, dose, quantity dispensed, balance, manufacturer number, and patient's signature.
Source: 
American Academy of Addiction Psychiatry (AAAP)
4.333335
Your rating: None Average: 4.3 (3 votes)
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