Provide a concise SOAP note for a stable patient on Suboxone (buprenorphine 8 mg/naloxone 2 mg daily) for opioid use disorder with no cravings, negative urine drug screen, and normal vital signs.

SOAP Note Template for Stable Patient on Suboxone Maintenance

Subjective

Chief Complaint:

• "Here for my regular Suboxone follow-up" 1

Opioid Use Disorder Status:

• No cravings for opioids 1, 2
• No illicit opioid use since last visit 1, 3
• Medication adherence: Taking buprenorphine/naloxone 8 mg/2 mg daily as prescribed 1, 3
• No withdrawal symptoms (sweating, muscle aches, anxiety, insomnia) 1, 3

Substance Use Assessment:

• Denies alcohol use 1
• Denies benzodiazepine use 1
• Denies cocaine, methamphetamine, or other illicit substances 1

Psychosocial Stability:

• Stable housing situation 1
• Employment status: [employed/seeking employment/disabled] 1
• Support system: Engaged with family/friends and attending [NA/AA/SMART Recovery] meetings regularly 1

Mental Health:

• Denies depression, anxiety, or suicidal ideation 1
• Sleep quality: Good, no insomnia 1

Review of Systems:

• No fever, chills, or night sweats 1
• No acute pain requiring additional analgesia 4
• No injection site complications or skin infections 1

Objective

Vital Signs:

• Blood pressure: [e.g., 118/76 mmHg] 1
• Heart rate: [e.g., 72 bpm] 1
• Respiratory rate: [e.g., 16/min] 1
• Temperature: [e.g., 98.6°F] 1

Physical Examination:

• General: Alert, well-appearing, no acute distress 1
• Skin: No track marks, abscesses, or signs of injection drug use 1
• Cardiovascular: Regular rate and rhythm 1
• Respiratory: Clear to auscultation bilaterally 1

Laboratory Results:

• Urine drug screen: Positive for buprenorphine, negative for opioids, cocaine, amphetamines, benzodiazepines 4, 1, 3
• Liver function tests: Not routinely required for buprenorphine/naloxone maintenance (unlike naltrexone) 1

Prescription Drug Monitoring Program (PDMP):

• Reviewed: No concerning prescriptions from other providers 4

Assessment

Primary Diagnosis:

• Opioid use disorder, in sustained remission on medication-assisted treatment with buprenorphine/naloxone 1, 5

Treatment Response:

• Excellent adherence to current regimen 3, 2
• Stable psychosocial environment supporting recovery 1
• No evidence of diversion or misuse 3, 2

Plan

Medication Management:

• Continue buprenorphine/naloxone 8 mg/2 mg sublingual daily 1, 3, 2
• Dispense 30-day supply with [0-2] refills based on stability 3
• Target maintenance dose range is 8-16 mg daily; current dose appropriate 1, 3, 2

Monitoring:

• Next follow-up visit in [2-4 weeks for newer patients; monthly for stable patients] 3, 2
• Continue random urine drug testing at each visit 4, 1, 3
• Review PDMP at each visit 4

Psychosocial Support:

• Continue participation in mutual-help groups (NA/AA/SMART Recovery) 1
• Maintain engagement with counseling/behavioral therapy 4, 1, 3

Patient Education:

• Reinforced importance of medication adherence to prevent relapse 1, 3
• Discussed that abrupt discontinuation markedly increases overdose risk due to reduced tolerance 1
• Reviewed safe storage to prevent diversion 3, 2
• If acute pain develops: Continue current Suboxone dose and contact office for short-acting opioid analgesics as needed; higher doses may be required due to buprenorphine's high receptor affinity 4, 1

Preventive Care:

• Naloxone rescue kit: [Provided/Renewed] for overdose prevention 4
• Hepatitis C and HIV screening: [Up to date/Order today] 1

Duration of Treatment:

• No maximum duration; continue indefinitely as long as patient benefits and treatment goals are met 3, 5