Clinic Toolkit for Methadone Providers - Assessment Forms and General Clinic Documents

Origin: Dr. Michael Lester and Dr. Lisa Lefebvre, CAMH

Format: Word

This form is used when assessing new clients. It is designed to record the clinical history of a patient presenting with problematic substance use. It also includes information intended for all patients regarding confidentiality; it is recommended that a health practitioner review this text with all patients, and ask them to sign indicating that they understand and accept the disclosure terms outlined.

Consent to Disclose Personal Health Information

Origin: MOHLTC | Format: Word

This form is to be signed when requesting information from another health care provider or facility, or when providing information to same.

CPSO Methadone Maintenance Patient Treatment Record

Origin: CPSO | Format: PDF

The CPSO, which maintains a registry of all patients receiving methadone in Ontario, requires that this form be submitted for every initiation and cessation of an MMT patient. The form can be filled in onscreen using Adobe software, or it can be printed and the information typed in. Completed forms should be faxed to the CPSO at
416 967-2635. For more detailed information on filling out this form, see the instruction sheet (also included in this toolkit—described below) or contact the CPSO Methadone Program directly at 416 967-2661.

CPSO Methadone Patient Treatment Transfer Form

Origin: CPSO | Format: Word

This form should be used when a patient is transferred from one doctor to another in the same group practice (it must be submitted even if both doctors are within the same clinic). Completed forms should be faxed to the CPSO at 416 967-2635. For more detailed information on filling out this form, see the instruction sheet (also included in this toolkit—described below) or contact the CPSO Methadone Program directly at 416 967-2661.

CPSO Methadone Maintenance Treatment Forms: Instructions for Completion

Origin: CPSO | Format: PDF

This document includes detailed information on filling out the CPSO’s Methadone Maintenance Patient Treatment Record and Methadone Patient Treatment Transfer Form (both described above). It lists the required fields and outlines how to use the forms for initiation, cessation
or transfer.

CPSO Methadone Exemption Clinical Training Session Guidelines

Origin: CPSO | Format: PDF

This document provides an outline of a clinical training session for a physician new to methadone prescribing.

Methadone Overdose information

Origin: CPSO, CAMH | Format: PDF

This file contains three documents, developed in partnership between CPSO and CAMH, designed to assist physicians, patients and emergency room staff in the event of a potential methadone overdose, and to ensure that physicians who prescribe methadone take the necessary steps to avoid an adverse outcome in a methadone overdose scenario. Together with the Refusal of Medical Care Release (“AMA Form”), it composes Appendix K of the CPSO Methadone Maintenance Guidelines (2005), which was added in 2007 in response to recommendations from coroners’ inquests that occurred after the release of the main guidelines.

Refusal of Medical Care Release (“AMA Form”)

Origin: CPSO, CAMH | Format: Word

This form provides a record of situations where medical care was offered but refused. Originally drafted by CAMH, it is included in Appendix K of the CPSO Methadone Maintenance Guidelines.

Clinical Opiate Withdrawal Scale (COWS) Flowsheet

Origin: ASAM | Format: Word

The Clinical Opiate Withdrawal Scale (COWS) is an assessment tool for opioid withdrawal and may be useful during the induction process for buprenorphine therapy. A reference for this instrument is included at the end of the page.

Clinic Toolkit for Methadone Providers - Assessment Forms and General Clinic Documents

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