Medication Consult Team

Patient intake

**Date:** [Insert date] **Patient ID:** [Insert patient ID] **Reason for admission / Patient goals:** [Describe reason for admission and patient’s stated goals]

Alcohol

**First exposure:** [Describe age or circumstances of first alcohol use] **Problematic use duration:** [State duration of problematic alcohol use] **Usual amount/pattern:** [Describe typical consumption and pattern] **Last use:** [Date or timeframe of last use] **Withdrawal history (multiple episodes, seizures, delirium, hallucinosis):** [Summarize withdrawal history] **Use history (blackouts, non-beverage alcohol use):** [Describe any blackouts or use of non-beverage alcohol] **Treatment history (inpatient/outpatient):** [Summarize prior treatment attempts] **Relapse prevention medications:** [List any relapse prevention medications] **History of abstinence:** [Describe any periods of abstinence] **Additional info (PAWSS):** [Include PAWSS score or relevant details]

Opioids

**First exposure:** [Describe age or circumstances of first opioid use] **Current amount/pattern/route:** [Describe current use, amount, frequency, and route] **Last use:** [Date or timeframe of last use] **Current OAT (Methadone, Suboxone, Sublocade, Kadian, iOAT, other):** [Specify current opioid agonist therapy] **Dose/dispensation:** [List dose and dispensation details] **Prescriber/clinic:** [Name prescriber or clinic] **Pharmacy:** [Name pharmacy] **Contaminated supply (benzodiazepine, other):** [Note any known contamination] **History of abstinence:** [Describe any periods of abstinence] **Previous OAT - methadone, suboxone, Kadian (max dose, effectiveness):** [Summarize previous OAT trials] **Treatment history (inpatient/outpatient):** [Summarize prior treatment attempts] **Overdose history:** [Indicate history of overdose (No/Yes) and details] **Additional info:** [Provide any additional relevant information]

Stimulants

**Cocaine / Crystal Methamphetamine** **First exposure:** [Describe age or circumstances of first stimulant use] **Last use:** [Date or timeframe of last use] **Current amount/pattern/route:** [Describe current use, amount, frequency, and route] **Treatment history (inpatient/outpatient):** [Summarize prior treatment attempts] **History of abstinence:** [Describe any periods of abstinence] **Additional info:** [Provide any additional relevant information]

Other substances

**Cannabis, Benzodiazepines, GHB, Hallucinogens, Inhalants, etc.:** [List use history and relevant details for other substances]

Tobacco (Nicotine)

**First exposure:** [Describe age or circumstances of first tobacco use] **Current amount/pattern/route:** [Describe current use, amount, frequency, and route] **Previous quit attempts:** [Summarize quit attempts] **Additional info:** [Provide any additional relevant information]

Harm reduction

**Injection drug use (present/past/never):** [Specify injection drug use history] **Access to safe injection supplies:** [Describe access to supplies] **Awareness of OPS/SCS, online/app resources (Lifeguard, NORS):** [Indicate awareness of harm reduction resources] **Use with others or nearby:** [Describe use patterns regarding supervision] **Use of test doses:** [Note if patient uses test doses] **Access to THN kits:** [Describe access to take-home naloxone kits] **Additional info:** [Provide any additional relevant information]

Past medical history

**HIV/Hep C:** [Indicate status and details] **Other medical diagnoses:** [List other relevant medical diagnoses] **Psychiatric diagnosis:** [List psychiatric diagnoses] **History of suicidal ideation or suicide attempt:** [Describe history] **Current suicidal ideation:** [Describe current status] **Family history:** [Summarize relevant family history] **COVID vaccinated (Y/N):** [Indicate vaccination status] **LNMP:** [Last normal menstrual period, if applicable]

Allergies

[List all known allergies and reactions]

Social history

**Housing:** [Describe current housing situation] **Employment/Finances:** [Describe employment and financial status] **Family/Children/Relationships:** [Summarize family, children, and relationship status] **Additional info:** [Provide any additional relevant information]

Physical exam

**BP:** [Insert blood pressure] **HR:** [Insert heart rate] **RR:** [Insert respiratory rate] **Mental status exam:** [Summarize findings] **Subjective report (withdrawal/intoxication):** [Describe patient’s subjective report] **Objective findings (withdrawal/intoxication):** [Describe objective findings] **Additional exam findings:** [Provide any additional relevant findings]

Investigations

**UDT:** [Urine drug test results] **Creatinine:** [Insert value] **GFR:** [Insert value] **INR:** [Insert value] **PLT:** [Insert value] **Albumin:** [Insert value] **AST:** [Insert value] **ALT:** [Insert value] **Bili:** [Insert value] **GGT:** [Insert value] **ECG:** [Insert findings] **Other:** [List any other relevant investigations]

Impression

**Diagnosis (Alcohol Use Disorder, Opioid Use Disorder, Stimulant Use Disorder, Tobacco Use Disorder, Benzodiazepine Use Disorder, other):** [State diagnosis] **Status (active/remission, mild/moderate/severe, early/sustained):** [Describe status] **Comments:** [Provide additional comments or clinical impressions]

Plan

**Acute withdrawal management, stabilization, relapse prevention, pharmacological and psychosocial support options, harm reduction:** [Outline management plan] **Additional plan details:** [Provide further details as needed]

Physician name and signature

**Name:** [Insert physician name] **Signature:** [Insert signature or electronic attestation]

Discharge summary CC

**CC to:** [List names or services to receive discharge summary]