NIATx Buprenorphine Implementation Toolkit
Sample Form: MAT Med Count Sheet

02/2017

Medication Count Sheet

Instructions: Complete this tool for each client called for medication counts.
1. Place the original in the chart’s medical section.

2. Placea copy in the MAT folder in IOP or in OP Reception.
3. Count quantity: “a” is the number counted today, “b” is the number that should be left today. For a correct count, “a” and “b” should be the same number. (See page 2, Medication Count Sheet)

4. Indicate actions: For example, “ Called MD,”“phase change,”“change in LOC,”“team meeting,”“dx’d,” etc.

Client NamePhone

Date & Time Called L/M or Spoke with client (Circle one)

Type of Medication / Reconciliation / Count Correct? / Quantity
(a/b =)
Suboxone / mg x per day / Yes / No
Subutex / mg x per day / Yes / No
Benzodiazepines
mg x per day / Yes / No
mg x per day / Yes / No
mg x per day / Yes / No
Stimulants / Yes / No
mg x per day / Yes / No
mg x per day / Yes / No
mg x per day / Yes / No
Other / Yes / No
mg x per day / Yes / No
mg x per day / Yes / No
mg x per day / Yes / No

Actions:  Staff at next MAT Huddle (date)

Comments:

Staff SignatureClient SignatureDate

MAT Medication Count Sheet

# of Days Left on Script / Number of Pills Prescribed Daily
1 / 1.5 / 2 / 2.5 / 3 / 4 / 5
1 / 1 / 1.5 / 2 / 2.5 / 3 / 4 / 5
2 / 2 / 3 / 4 / 5 / 6 / 8 / 10
3 / 3 / 4.5 / 6 / 7.5 / 9 / 12 / 15
4 / 4 / 6 / 8 / 10 / 12 / 16 / 20
5 / 5 / 7.5 / 10 / 12.5 / 15 / 20 / 25
6 / 6 / 9 / 12 / 15 / 18 / 24 / 30
7 / 7 / 10.5 / 14 / 17.5 / 21 / 28 / 35
8 / 8 / 12 / 16 / 20 / 24 / 32 / 40
9 / 9 / 13.5 / 18 / 22.5 / 27 / 36 / 45
10 / 10 / 15 / 20 / 25 / 30 / 40 / 50
11 / 11 / 16.5 / 22 / 27.5 / 33 / 44 / 55
12 / 12 / 18 / 24 / 30 / 36 / 48 / 60
13 / 13 / 19.5 / 26 / 32.5 / 39 / 52 / 65
14 / 14 / 21 / 28 / 35 / 42 / 56 / 70
15 / 15 / 22.5 / 30 / 37.5 / 45 / 60 / 75
16 / 16 / 24 / 32 / 40 / 48 / 64 / 80
17 / 17 / 25.5 / 34 / 42.5 / 51 / 68 / 85
18 / 18 / 27 / 36 / 45 / 54 / 72 / 90
19 / 19 / 28.5 / 38 / 47.5 / 57 / 76 / 95
20 / 20 / 30 / 40 / 50 / 60 / 80 / 100
21 / 21 / 31.5 / 42 / 52.5 / 63 / 84 / 105
22 / 22 / 33 / 44 / 55 / 66 / 88 / 110
23 / 23 / 34.5 / 46 / 57.5 / 69 / 92 / 115
24 / 24 / 36 / 48 / 60 / 72 / 96 / 120
25 / 25 / 37.5 / 50 / 62.5 / 75 / 100 / 125
26 / 26 / 39 / 52 / 65 / 78 / 104 / 130
27 / 27 / 40.5 / 54 / 67.5 / 81 / 108 / 135
28 / 28 / 42 / 56 / 70 / 84 / 112 / 140
29 / 29 / 43.5 / 58 / 72.5 / 87 / 116 / 145
30 / 30 / 45 / 60 / 75 / 90 / 120 / 150
31 / 31 / 46.5 / 62 / 77.5 / 93 / 124 / 155

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