Dare to Document
What format should be followed for documentation, where applicable, including notes and treatment plans?
SMART Format (Specific, Measurable, Attainable, Realistic, Time-Bound).
Federal Regulations states the initial dosage of methadone should not exceed____ and the cumulative amount of methadone given on day one will not be greater than ____.
30MG, 40MG (Federal Regulations, pg. 52)
True or False: It is recommended that patients remain in methadone maintenance treatment if they are still abusing substances rather than leaving treatment or being discharged.
True, unless substance(s) of abuse present safety concerns, in which other treatment options and interventions should be explored (Federal Regulations, pg. 34)
Federal regulations states that OTPs should take reasonable measures to prevent multiple program enrollment. What does DCHC currently do to comply with this?
Clients sign the Dual Enrollment Form and it is faxed to all OTPs within a reasonable geographic distance prior to admission (Federal Regulations, pg. 48)
Frank and Marsha, a married couple both enrolled in MAT treatment at DCHC, present in the dosing waiting room. They always attend the clinic together and openly discuss how they’re feeling and their dose. Frank doses first and tells Marsha he will be outside smoking. Marsha presents to the dosing window and engages in conversation with the dispensing staff. Marsha asks, “just out of curiosity, what is Frank’s dose currently? He told me he wasn’t feeling good and I’m wondering if his dose isn’t working for him”. What do you say/do and why?
There are a few things the dispensing staff can do that ensure confidentiality:
When referring to recordkeeping and documentation, Federal Regulations states programs should ensure these two qualities in their recordkeeping.
efficient and avoid duplication (Federal Regulations, pg. 46)
The Federal Regulations states that voluntary, written, program specific informed consent to treatment with the specific pharmacotherapy ordered by the physician is received prior to medicating the patient. This includes all treatment procedures, services, and other policies and regulations throughout the course of treatment. How does DCHC capture this, and who is responsible for this?
This is achieved by client’s signing the Informed Consent to Treatment with intake clinician and Consent to Treatment with Approved Narcotic with intake physician. (Federal Regulations, pg. 23-24)
True or False: Per Federal Regulations, a physician may choose not to increase a client’s dose due to nonpayment of fees or lack of engagement with clinical services.
False. The Federal Regulations indicate that OTPs should avoid establishing procedures or policies that hind the ability of physicians, as appropriate, to adjust patient dosages whenever the need is indicated. (Federal Regulations, pg. 51)
What are the 3 desired outcomes for effective medication-assisted treatment, as outlined by the Federal Regulations?
(Federal Regulations, pg. 51-52):
Nathan comes to you for dose evaluation for reports experiencing the following: withdrawal symptoms upon waking, consistent dose of 120MG taken at roughly 9am, after an hour is feeling better. Hasn’t missed dose or concurrently using other substances. By 12-1pm, client reports feeling the need to take a nap every day, and generally does so. By later in the evening and throughout the night, withdrawal symptoms begin again and persist until next day’s dose, he sometimes supplements with opiate use at night to relieve symptoms. Client denies any recent changes in lifestyle or medication. What are your recommendations?
Client should be further assessed for a possible split dose of methadone. (TIP 43, pg. 28-29)
PA State Regulations requires informed and voluntary written consent by the client prior to release of information contained in the client record. What 6 things must, at a minimum, be included on this consent to disclose information?
What is a steady-state concentration of methadone and generally how long until it is reached?
The point at which the amount of drug entering the body is equal to the amount excreted; typically achieved 5-7.5 days (4-5 half lives of the medication) following patient induction into methadone. (Federal Regulations, pg. 52)
True or False: There should be no limits on patients’ duration of treatment or dosage level of medication for methadone maintenance?
True (Federal Regulations, pg. 35)
Federal regulation stipulates that documentation in patient records should be kept confidential and up to date. How does DCHC comply with this via policies on documentation and access to client records?
RCA policies reflect all significant interactions with clients should be documented in DAP format in the client’s chart immediately proceeding the event or at the latest by the end of the shift. Documentation should be completed in one designated location within the chart to avoid duplication of information entry and only be accessible to individuals within the client’s treatment team.
What is DCHC's process for bottle call backs? Include what is assessed and any "red flags".
Nicole has to verify if answer is correct.
Federal Regulations states there are 15 things that should be included in an individual patient record. Name 5 of them.
(Federal Regulations, pg. 46-47)
What is a “Standing Order” and what are the guidelines regarding its use in OTPs?
Standing Orders are defined as orders that apply equally to all persons fulfilling certain criteria or any formulaic policy generically applied to all patients meeting specific criteria or specific situations without evaluation by a physician. Examples include dose adjustments based solely on COWS and fixed percentages adjustments for missed doses. Standing Orders regarding dose, schedule, or re-administration of methadone are not appropriate. (Federal Regulations, pg. 51)
True or False: There should be no limitations on the psychosocial services offered to patients, even when they no longer take methadone.
True (Federal Regulations, pg. 35)
What is “Informed Consent”? What does informed consent apply to within DCHC?
Informed means that the patient has been educated and are fully aware of what they are signing prior to consent being given. All information is being provided to the client and all forms are 100% filled out prior to obtaining signature indicating consent. This applies to consents to treatment and release of information forms. (State Regulations, PA 709.28).
Larry presents for an intake. He reports he has been using opiates for the last 13 months and is interested in methadone maintenance treatment. Upon further assessment, the following information is discovered: Larry fits the criteria for having Opioid Use Disorder, Moderate. Larry denies having withdrawal symptoms currently or when he has attempted to cut down in the past. For the reported 13 months of opiate use, Larry reports he has consistently used apx. 50MG of Percocet without developing an increased need for more over time. Does Larry qualify for MMT? Explain why or why not in your answer, and how you would proceed.
The Federal Regulations stipulate that a patient must be determined to be “currently addicted to an opioid drug”. If a patient has a mild or moderate OUD without meeting criteria for tolerance/withdrawal, opioid agonist medications that will themselves produce physical dependence must be carefully considered and other options such as psychotherapy or antagonist pharmacotherapy such as oral/inject-able naltrexone should be considered. (Federal Regulations, pg. 21-22)
Federal Regulations stipulate that an OTP program include what 5 pieces of information into their informed consent form(s) at admission?
What are the 3 main concerns regarding the use of Standing Orders for dose, schedule, or re-administration?
(Federal Regulations, pg. 51):
The Federal Regulations clearly state that dose adjustments should never be used for this reason.
To reinforce/punish behavior (Federal Regulation, pg. 52)
In general, it is advised that dose increases should be made with this amount of time in between. What is the reason for this?
Several days. Methadone has a long half-life and accumulates in the body with repeated dosing (even if repeated dosing with same dose each day). The full effect of a single dose increase may not be appreciated for several days If dose is increased too fast, it increases the risk of toxicity to build and increases risk of death. (Federal Regulations, pg. 52)
Susan presents for an intake. She was treated with methadone maintenance in the past, and discharged 11 months ago. She reports she has not used opiates since her discharge, but is seeking admission to methadone maintenance treatment because she is going through a difficult time and fears relapse. She does not present with evidence of current use or withdrawal symptoms. Does she qualify for MMT? Explain why or why not in your answer.
She qualifies under the exception of previously treated patients up to 2 years post-discharge (Federal Regulations, pg. 22)