Addiction Medicine Specialist - Follow-Up Review Note

Follow-Up Review Note Review Date: [insert date of review and specify type of follow-up (e.g. routine clinic review, early relapse review, telephone/virtual follow-up, community/home visit, DOTS follow-up, NGO-linked outreach)] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Substance Use Since Last Visit: [record any self-reported substance use (e.g. alcohol, cannabis, nyaope, methamphetamine, codeine) or objective findings such as urine drug screen results, collateral information, or clinician observation] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Medication Adherence: [comment on adherence to prescribed medications including ART, TB treatment, methadone/buprenorphine, psychiatric medications, chronic disease meds; include any side effects reported, missed doses, or changes in regimen] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Withdrawal or Craving Symptoms: [document any reported withdrawal symptoms (e.g. sweating, tremor, nausea, anxiety), cravings (intensity, triggers), and coping or harm reduction strategies used by patient] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Mental and Physical Health Status: [review mental state (mood, sleep, concentration, suicidal thoughts), and any physical complaints or comorbidities such as HIV, TB, hypertension, or seizures] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Social Functioning: [update on employment status, income, social support network, housing stability (e.g. formal/informal housing, shelters), legal issues, access to social grants (e.g. SASSA disability or child support grants), and family or community support] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Plan: [document updates to treatment or management plan: medication adjustments, referrals (e.g. social work, psychology, rehab, legal aid), date of next review, transport arrangements if relevant, or need for further investigation] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output; just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)