Documentation Challenges in Addiction Medicine

• Adhering to 42 CFR Part 2 confidentiality requirements for substance use records
• Documenting medication-assisted treatment with DEA X-waiver compliance
• Tracking validated screening tools like AUDIT, DAST, and COWS scores serially
• Balancing detailed clinical documentation with patient stigma concerns
• Meeting state-specific prescribing documentation requirements for controlled substances

Note Types for Addiction Medicine

• Initial Assessment

  Comprehensive substance use evaluation with ASAM criteria and treatment level determination

• MAT Management Notes

  Buprenorphine, methadone, or naltrexone prescribing visits with dosing and response documentation

• Follow-Up Notes

  Treatment progress, toxicology results, relapse assessment, and care plan updates

• Group Therapy Documentation

  Group session notes with attendance, themes, participation level, and individual observations

Key Features for Addiction Medicine

• 42 CFR Compliance

  Documentation structured to meet substance use record confidentiality requirements

• MAT Tracking

  Medication dose tracking, PDMP documentation, and prescribing compliance

• Screening Integration

  Automated AUDIT, DAST, COWS, and CIWA scoring with serial trending

• Rapid Group Notes

  Multi-participant group session documentation in minutes

Stats

• 2 hrs - Saved Daily
• 45 sec - Follow-Up Notes
• 100% - 42 CFR Compliant
• 30% - More Patients Served

Testimonial

My patients are in their most vulnerable moments. Scribeable lets me stay present during sessions and handles the documentation burden, including the specific compliance requirements that make addiction medicine notes so time-consuming.