MAT note requirements 2026

MAT notes sit under 42 CFR Part 2, plus SAMHSA, DEA, state, and payer rules. This is what the 2026 note has to contain for buprenorphine, methadone, and naltrexone.

Initial intake

The initial MAT intake is longer than a routine visit because it has to establish medical necessity, document informed consent, capture the substance-use history that supports the diagnosis, and start the safety and monitoring plan.

Required sections at intake:

• Full substance-use history (substances, age of first use, current use pattern, prior treatment history, periods of remission).
• Medical history relevant to MAT (liver function, cardiac history, pregnancy status, current medications including controlled substances).
• Mental health history including suicidality, self-harm, and current psychiatric diagnoses.
• DSM-5 substance use disorder diagnosis with severity specifier.
• Current functional status (housing, employment, family, legal).
• Current symptom status (withdrawal symptoms today, COWS score for opioid users, CIWA for alcohol).
• Treatment plan including induction protocol, follow-up cadence, monitoring plan, and counseling referral.
• Informed consent: medication risks and benefits, alternatives discussed, treatment agreement signed.
• Baseline UDS result.
• Naloxone prescription documented (for opioid MAT).

Buprenorphine specifics

Buprenorphine has the most flexible federal framework after the X-waiver removal in 2023. Keep the documentation standard rigorous. Audits are common.

• Each visit: dose, fills since last visit, evidence of taking the medication as prescribed (UDS or self-report with corroboration), withdrawal/craving status, side effects, functional status, and counseling participation.
• Dose escalations require a documented clinical rationale.
• Diversion concerns (early refill requests, missed appointments, UDS results inconsistent with the prescription) require a documented response: counseling discussion, increased visit frequency, supervised dosing if applicable, or referral to a higher level of care.
• Ongoing UDS at a frequency consistent with patient stability (typically monthly in the first three months, then quarterly in stable patients, more often if there is concern).

Methadone specifics

Methadone for opioid use disorder is regulated at the federal OTP (opioid treatment program) level. The documentation is more prescriptive.

• Initial induction: state rules vary. Typical practice is supervised dosing with daily reassessment for the first weeks. Each daily dose visit needs dose, observed administration, baseline vitals if first dose, and clinical status.
• Take-home doses: each take-home requires documented eligibility against the SAMHSA take-home criteria (8 axes: absence of recent abuse, regularity of attendance, absence of behavioral problems, absence of recent criminal activity, stability of home environment, length in treatment, assurance of safe storage, rehabilitative benefit).
• Annual review: annual documentation of treatment plan review, justification for ongoing maintenance, and any updates.

Naltrexone (extended-release injectable) specifics

Naltrexone is less heavily regulated. The documentation still has a pattern.

• Each injection visit: confirmation of opioid abstinence (typically 7+ days for opioid use disorder, naloxone challenge or UDS as protocol indicates), absence of acute opioid intoxication, injection site, dose, and observation period.
• Liver function monitoring at baseline and periodically.
• Documented counseling about the risk of overdose if relapse occurs after the dose wears off.

Per-visit ongoing documentation

For all MAT regimens, the ongoing visit note needs:

• Substance use since last visit (with corroborating UDS).
• Medication adherence.
• Withdrawal/craving status (use validated scales when applicable).
• Functional status in 4 domains: physical, psychiatric, social, occupational.
• Counseling participation (or documentation of referral and outcome).
• Plan: continue, adjust, or escalate.

42 CFR Part 2 considerations

MAT records are SUD records under 42 CFR Part 2. The documentation does not change. The handling of records does. Disclosure to outside parties requires patient consent in the Part 2 format, even within the same health system in many cases. The chart should show that the patient was informed of the confidentiality protections and any limits.

Sample assessment language for ongoing visits

A defensible MAT assessment for an ongoing visit:

Patient is an N-year-old [demographics] with opioid use disorder, severe, in [early/sustained] remission on [medication and dose]. At today’s visit, patient reports [no/minimal/moderate/severe] cravings, [no/some] withdrawal symptoms, and [no use/use] since last visit. UDS today is [result], consistent/inconsistent with prescription. Functional status [stable/improving/worsening] in [domains]. Counseling [participation summary]. Plan: continue current dose, follow-up in [interval], next UDS [interval].

The Nextvisit MAT template at /templates covers this format and the buprenorphine, methadone, and naltrexone variants. Dose, UDS, and COWS or CIWA land as data, not HPI prose. Missing required elements show up before you sign.