What elements should be included in a template for a Suboxone (buprenorphine/naloxone) visit?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: December 9, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Suboxone Visit Medical Note Template

A comprehensive Suboxone visit template should include documentation of withdrawal assessment, substance use patterns, medication adherence, psychosocial support, safety monitoring, and treatment planning, as these elements align with evidence-based office-based opioid treatment protocols. 1

CHIEF COMPLAINT / VISIT TYPE

  • Initial Suboxone visit
  • Follow-up visit (specify interval: _____)
  • Medication refill
  • Dose adjustment
  • Crisis/urgent visit

Free text: _______________________

SUBSTANCE USE HISTORY (Current Visit)

Opioid Use Since Last Visit

  • No opioid use
  • Occasional use (_____ times in past _____ days)
  • Regular use (describe pattern: _______)
  • Last opioid use: Date/time: _____ Type: _____ Amount: _____
  • Urine drug screen results: Date: _____ Results: _____

2

Other Substance Use

  • Alcohol: _____ drinks/week
  • Benzodiazepines (contraindicated with buprenorphine due to respiratory depression risk) 3
  • Cocaine: _____
  • Methamphetamine: _____
  • Cannabis: _____
  • Other: _____

1

WITHDRAWAL ASSESSMENT

Clinical Opiate Withdrawal Scale (COWS) Score

Current COWS score: _____ (document if initiating or adjusting dose)

  • Resting pulse rate: _____
  • Sweating: _____
  • Restlessness: _____
  • Pupil size: _____
  • Bone/joint aches: _____
  • Runny nose/tearing: _____
  • GI upset: _____
  • Tremor: _____
  • Yawning: _____
  • Anxiety/irritability: _____
  • Gooseflesh: _____

Note: COWS >8 required for buprenorphine initiation 2

CURRENT MEDICATION REGIMEN

Buprenorphine/Naloxone Dosing

  • Current dose: _____ mg daily (or _____ mg BID if split dosing)
  • Formulation: [ ] Sublingual tablet [ ] Sublingual film
  • Adherence: [ ] Taking as prescribed [ ] Missed doses (specify: _____) [ ] Taking more than prescribed
  • Time of last dose: _____
  • Medication storage: [ ] Secure location confirmed [ ] Out of reach of children 3

3, 4

Concurrent Medications Review

  • Serotonergic medications (risk of serotonin syndrome): _____
  • QT-prolonging medications (cardiac arrhythmia risk): _____
  • Benzodiazepines (4-fold increased overdose risk - document justification if prescribed): _____
  • Other medications: _____

2, 3, 5

SYMPTOM ASSESSMENT

Withdrawal Symptoms

  • None
  • Shaking
  • Sweating
  • Hot/cold flashes
  • Runny nose/watery eyes
  • Goosebumps
  • Diarrhea
  • Vomiting
  • Muscle aches

3

Side Effects

  • Nausea
  • Vomiting
  • Headache
  • Sweating
  • Numb mouth/painful tongue
  • Constipation
  • Dizziness/lightheadedness
  • Sleepiness
  • Insomnia
  • Blurred vision
  • Palpitations

3

Concerning Symptoms (Require Immediate Attention)

  • Respiratory problems/difficulty breathing
  • Severe sleepiness or confusion
  • Jaundice (yellowing of skin/eyes)
  • Dark urine or light-colored stools
  • Severe abdominal pain
  • Rash, hives, facial swelling
  • Signs of serotonin syndrome (agitation, clonus, altered mental status)

3, 5

PAIN ASSESSMENT

Current pain: [ ] None [ ] Mild [ ] Moderate [ ] Severe Location/description: _____

Pain management plan:

  • Continue Suboxone only (note: provides minimal analgesia for acute pain) 6
  • Split Suboxone dosing to q6-8h for enhanced analgesia 6
  • Add supplemental full opioid agonist (requires 1.5-2x standard dose) 6
  • Non-opioid analgesics: _____
  • Coordination with pain specialist/surgeon: _____

6

PSYCHOSOCIAL ASSESSMENT

Support Systems

  • Counseling/therapy: [ ] Active [ ] Not engaged [ ] Referral needed
  • Frequency: _____
  • Type: [ ] Individual [ ] Group [ ] Cognitive behavioral therapy
  • Support groups: [ ] NA/AA [ ] SMART Recovery [ ] Other: _____

1

Motivational Interviewing Elements

  • Patient's reasons for change: _____
  • Concerns about substance use: _____
  • Confidence in recovery (1-10): _____
  • Affirmations provided: _____

1

Functional Status

  • Employment/school: [ ] Stable [ ] Unstable [ ] Not applicable
  • Housing: [ ] Stable [ ] Unstable [ ] Homeless
  • Legal issues: [ ] None [ ] Pending [ ] Active
  • Family/social relationships: _____

1

PHYSICAL EXAMINATION

Vital Signs

  • BP: _____ (monitor for hypotension) 3
  • HR: _____ (monitor for palpitations) 3
  • RR: _____ (monitor for respiratory depression) 3
  • Temp: _____
  • Weight: _____

Focused Exam

  • General appearance: [ ] Alert [ ] Sedated [ ] Intoxicated [ ] Withdrawal signs
  • Pupils: [ ] Normal [ ] Dilated [ ] Constricted
  • Oral exam: [ ] Normal [ ] Tongue swelling/redness [ ] Dental issues
  • Skin: [ ] Normal [ ] Jaundice [ ] Track marks [ ] Rash
  • Mental status: [ ] Alert and oriented x3 [ ] Altered [ ] Agitated

3, 5

LABORATORY MONITORING

Required Testing

  • Urine drug screen: Date: _____ Results: _____
  • Liver function tests: Date: _____ Results: _____ (monitor for hepatotoxicity) 3
  • Hepatitis C screening: [ ] Negative [ ] Positive [ ] Due [ ] Declined
  • HIV screening: [ ] Negative [ ] Positive [ ] Due [ ] Declined

1, 2, 3

Additional Testing (As Indicated)

  • Pregnancy test (if applicable): _____
  • ECG (if on QT-prolonging medications): _____

2

HARM REDUCTION & PREVENTIVE CARE

  • Naloxone kit provided/reviewed (overdose prevention education) 2
  • Safe injection practices discussed (if applicable)
  • Contraception counseling (buprenorphine contraindicated in pregnancy per FDA label) 3
  • Infectious disease screening offered
  • Tobacco cessation discussed

2

ASSESSMENT & PLAN

Current Status

  • Stable on current dose
  • Withdrawal symptoms present
  • Side effects requiring management
  • Continued substance use
  • Non-adherent with medication
  • Non-adherent with counseling

Treatment Plan

Medication:

  • Continue current dose: _____ mg daily
  • Increase dose to: _____ mg daily (typical maintenance range 4-24 mg, most patients 16 mg) 2, 4
  • Decrease dose to: _____ mg daily
  • Split to BID dosing: _____ mg BID
  • Prescription provided for _____ days supply
  • Next refill date: _____

2, 4

Monitoring:

  • Return visit in _____ days/weeks
  • UDS at next visit
  • LFTs in _____ weeks/months
  • Coordinate with Suboxone prescriber if hospitalized 6

Psychosocial:

  • Continue current counseling
  • Referral to: _____
  • Increase counseling frequency
  • Support group engagement encouraged

1

Safety:

  • Medication storage reviewed (secure, out of reach of children) 3
  • Disposal instructions reviewed (flush unused tablets) 3
  • Drug interaction counseling provided
  • Avoid benzodiazepines (respiratory depression risk) 3
  • Serotonin syndrome warning if on serotonergic medications 5
  • Emergency contact information provided

3

Follow-up:

  • Routine follow-up in _____ weeks
  • Call if withdrawal symptoms, severe side effects, or concerns
  • Coordinate with treatment team as needed

CLINICAL DECISION SUPPORT NOTES

Dose Adjustment Considerations

  • Longer-term maintenance treatment is generally indicated (brief tapers associated with high relapse rates) 1
  • Most patients maintained on 16 mg daily (range 4-24 mg) 2, 4
  • Less frequent dosing possible (thrice weekly with dose multiples) but daily preferred initially 7, 4

Red Flags Requiring Immediate Action

  • Respiratory depression (especially with benzodiazepines or alcohol) 3
  • Signs of liver injury (jaundice, dark urine, light stools, abdominal pain) 3
  • Serotonin syndrome (agitation, clonus, altered mental status with serotonergic drugs) 5
  • Severe allergic reaction (rash, hives, facial swelling, wheezing) 3

Coordination Requirements

  • If patient hospitalized: Notify Suboxone program, verify current dose, coordinate discharge planning 6
  • If surgery planned: Discuss perioperative management (may continue for minor procedures, consider discontinuation for major surgery with significant pain) 6

Provider Signature: _____________________ Date: _____

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Buprenorphine/Naloxone Initiation Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Research

Buprenorphine: how to use it right.

Drug and alcohol dependence, 2003

5
Research

Serotonin syndrome triggered by a single dose of suboxone.

The American journal of emergency medicine, 2008

6
Guideline

Pain Management in Patients on Suboxone

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

Do people develop a tolerance to Suboxone (buprenorphine)?
What is the level of opioid receptor blockade at 16 mg/day and 24 mg/day of Suboxone (buprenorphine/naloxone)?
Can I withdraw from Suboxone (buprenorphine/naloxone) after a short induction and only one day of 8/2mg TID (three times a day)?
Can withdrawal from Suboxone (buprenorphine/naloxone) occur after 2 days of treatment at 24mg/day?
Should a patient start Brixadi (buprenorphine) weekly or monthly once stabilized on Suboxone (buprenorphine and naloxone)?
For cone compression, should I order diagnostic mammography with tomosynthesis?
Should LDL particle size determine statin therapy?
What is the recommended treatment for low thiamine (Vitamin B1) levels?
Is genetic testing for epilepsy, specifically the Invitae (Laboratory Corporation of America) gene panel, covered for a 13-year-old male patient with a new diagnosis of epilepsy and an HMO (Health Maintenance Organization) plan?
What is the recommended dose of acetaminophen (Tylenol) for an 80-pound child with fever?
What diagnostic test should be ordered after an abnormal screening mammogram for further evaluation?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question