Methadone Take-Home Dose Justification

Documents the clinical rationale and take-home eligibility criteria for methadone in an opioid treatment program, aligned to 42 CFR 8.12(i)(2) and SAMHSA guidance effective April 2024.

Record Context

• Patient Identifier
  Enter the internal patient identifier or medical record number. Do not enter SSN.
• Patient Name
  Enter the patient's legal name as it appears in the clinical record.
• Decision Date
  Date the take-home dose decision was made.
• Decision Type
• Requested Take-Home Days
  Number of take-home days requested or under consideration.

Clinical Eligibility Review

• Criteria Reviewed
  Select the factors reviewed in making this decision.
• Recent Substance Use Concerns
• Substance Use Concern Details
  Describe only the minimum necessary details relevant to the take-home decision.
• Diversion Risk Assessment
• Diversion Risk Rationale
  Explain the factors supporting the diversion risk assessment.

Safety and Storage

• Safe Storage Confirmed
• Planned Storage Method
  How the patient will store take-home doses securely.
• Other Storage Method
• Patient Understanding of Take-Home Instructions
• Education Provided

Clinical Rationale and Plan

• Clinical Rationale
  Summarize the clinical rationale for the take-home decision for the patient clinical record.
• Safeguards or Conditions
  Select any safeguards attached to the decision.
• Follow-Up / Reassessment Date
  Date for reassessment of take-home eligibility.
• Additional Notes
  Use only if needed to document clinically relevant information not captured above.

Attestation

• Attestation
  I attest that this take-home dose decision is based on a documented clinical review and will be maintained in the patient clinical record.
• Clinician Name
• Clinician Role
• Signature