Documentation Template for Controlled Substance Prescription
This patient is being prescribed [medication name and dose] for [indication], with appropriate safeguards in place to minimize risks of misuse, diversion, and overdose.
Clinical Assessment and Justification
Indication: Patient presents with [specific condition] requiring controlled substance management. The therapeutic objective is [specific goal]. 1
Risk Assessment: Patient has been evaluated for risk of addiction, abuse, and misuse prior to prescribing. No current evidence of aberrant drug-related behaviors, substance use disorder, or diversion risk identified at this time. 2, 1
Physical Examination: No signs of intoxication, impaired consciousness, or respiratory compromise noted. Vital signs stable. 1
Patient Education Provided
Safe Use Counseling: Patient counseled on:
- Proper dosing schedule and administration instructions 2
- Risks of addiction, abuse, misuse, respiratory depression, and overdose 1
- Absolute prohibition of concurrent alcohol or benzodiazepine use without explicit medical supervision 3, 1
- Signs and symptoms of overdose including severe drowsiness, slowed breathing, and unresponsiveness 2
- Importance of taking medication exactly as prescribed without dose escalation 1
Safe Storage: Patient instructed to store medication in secure location away from children and individuals at risk of misuse. Discussed use of lock boxes if household members have substance use history. 2
Naloxone Education: Patient and family educated on opioid overdose recognition and naloxone administration. Naloxone rescue kit prescribed and dispensing instructions provided. 2
Drug Interactions: Patient counseled to avoid all CNS depressants including alcohol, benzodiazepines, sedatives, and muscle relaxants unless explicitly approved by prescriber due to risk of fatal respiratory depression. 2, 1
Treatment Agreement and Monitoring Plan
Controlled Substance Agreement: Patient has reviewed, understands, and signed controlled substance treatment agreement outlining:
- Single prescriber and single pharmacy requirements 2
- Expectations for appropriate medication use 2
- Consequences of aberrant behaviors 2
- Agreement to random urine drug testing 2
- No early refills or replacement of lost/stolen medications 2
Monitoring Strategy:
- Follow-up scheduled in [timeframe] to assess therapeutic response and monitor for adverse effects 2
- Urine drug testing will be performed at regular intervals to confirm medication adherence and screen for illicit substances 2
- Prescription drug monitoring program (PDMP) checked prior to prescribing 2
Safety Precautions Documented
Contraindications Reviewed: No evidence of acute/severe respiratory depression, unmonitored severe asthma, paralytic ileus, or hypersensitivity to opioids. 1
High-Risk Conditions Assessed: Patient screened for chronic pulmonary disease, sleep apnea, renal/hepatic impairment, increased intracranial pressure, circulatory shock, and adrenal insufficiency. 1
Pregnancy/Reproductive Counseling: [If applicable] Patient counseled on risks of neonatal opioid withdrawal syndrome with prolonged use during pregnancy. 1
Disposal Instructions: Patient instructed on proper disposal methods for unused medication to prevent accidental ingestion or diversion. Poison control number (1-800-222-1222) provided. 2
Prescription Details
- Medication: [Name, strength, formulation]
- Quantity: [Specific number of units]
- Directions: [Exact dosing instructions]
- Refills: [Number, if any]
- Pharmacy: [Single designated pharmacy name]
Prescriber attestation: Benefits of opioid therapy assessed to outweigh risks of addiction, abuse, and misuse for this patient at this time. Will monitor regularly for development of problematic behaviors. 1