Intake History And Physical Page 3
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3Initial Treatment Plan:
Screening for Appropriateness for Buprenorphine Treatment
____ Laboratory testing: CBS, Chem Panel (ALT, AST, GGTP Tot Bili, Alk Phos, Glc, BUN Creatinine,
Chol/Trig), Urine Drug Screen (expaned panel for opioids)
Other:_____ Hepatitis Panel_____ HIV Antibody_____ Pregnancy Test (Urine/Serum)_____ ECG_____
____ TB test: placed date__________ to be read date__________
Initial Orders
____ admit to Buprenorphine maintenance/medical withdrawal treatment
Induction dose orders:
____ urine drug screen schedule
Counseling plans:
Next visit:
Maintenance Buprenorphine/Naloxone Dose:
Signed:
Date:
400 Massasoit Ave. Suite 307, 2nd Flr. | East Providence RI 02914| P: (888) 572-7724 F: (401) 272-0922 | Email:
|Twitter: @PCSSProjects
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