What should be included in a substance use disorder progress note?

Use since the last session (substance, amount, days of use, last use), cravings and triggers, test results, the client’s goal and readiness, the interventions you used, the client’s response, risk (withdrawal, overdose, suicide, driving) and the plan, including any coordination with prescribers.

How do you document relapse in a progress note?

Describe it factually: what was used, how much, when, what led up to it and what the client did afterwards. Avoid judgmental words such as “dirty.” Record any risk, such as overdose after a period without use, and how the plan changes.

Do you have to write in person-first language in SUD notes?

It is recommended. Phrases such as “person with a substance use disorder” and “positive test result” are more accurate and less stigmatizing than “addict” or “dirty urine,” and the note may be read by the client and other providers.

What is 42 CFR Part 2 and does it apply to my notes?

42 CFR Part 2 protects records from federally assisted programs that meet its definition of a program, including qualifying providers of SUD diagnosis, treatment or referral for treatment. Some requirements also apply to recipients of Part 2 records. Part 2 has consent and disclosure requirements in addition to HIPAA; check the applicable rules and exceptions before sharing notes.

What interventions are documented in SUD progress notes?

Common ones include motivational interviewing, CBT relapse prevention, contingency management, mutual-help facilitation and coordination with medication treatment. Name the specific technique and what it targeted, for example “MI decisional balance on weekend use.”

Progress Notes for Substance Use Disorder: Template + Examples (2026)

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Overview

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Short answer: a progress note for substance use disorder (SUD) records what was used since the last session (substance, amount, days of use, route), cravings and triggers, any test results, the client’s goal and stage of change, the interventions you used (for example motivational interviewing or CBT relapse prevention), the client’s response, risk (withdrawal, overdose, suicide, driving) and the plan. Use the client’s own goal, whether that is abstinence or reduced use, and record it in their words.

Counting days of use with a calendar method such as the Timeline Followback gives a clearer trend than “using less.” Record who prescribes any medication for the SUD and whether you coordinate with them. Records from federally assisted SUD programs are also protected by 42 CFR Part 2, which has its own consent and disclosure rules on top of HIPAA, so check whether your program is covered before sharing notes.

What to document in an SUD progress note

What to document in a substance use disorder progress note, with fictional example wording
Item	What to document	Example wording
Use since last session	Substance, amount, days of use, route, last use	“Cannabis vape on 3 of 7 days (was 7 of 7), last use 2 days ago.”
Cravings and triggers	Intensity, situations, what helped	“Cravings 6/10 after work; urge-surfed twice.”
Tests and measures	Urine drug screen or other results, screening scores	“Urine drug screen positive for THC, as expected given reported use.”
Goal and stage of change	Client’s goal in their words; readiness	“Goal: ‘no weekday use.’ Planning further weekday reduction; says he is not ready to stop weekend use. Explore weekend readiness with MI.”
Interventions	Named technique and what it targeted	“MI: decisional balance on weekend use; CBT: trigger plan for after-work cravings.”
Risk	Withdrawal, overdose, suicide, driving after use, other safety	“Denies driving after use since last session; no withdrawal symptoms beyond irritability.”
Plan	Practice tasks, coordination, level of care, next session	“Continue weekly outpatient individual therapy; use the after-work trigger plan and review the use calendar next session.”

Safety. Withdrawal from alcohol, benzodiazepines or other sedatives can be dangerous; seizures, confusion or hallucinations during withdrawal need emergency care: call 911 or go to the nearest emergency department. For opioid use, record overdose risk factors, such as a recent period without use, and whether the client has naloxone. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means (including firearms and medications), protective factors, your risk formulation and the safety plan. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.

Writing in the DAP format? See DAP notes for substance abuse, with an example.

How to Document Progress Notes for Substance Use Disorder

Session Summary

Overview of session focus, topics discussed, and client presentation

When documenting the Session Summary for substance use disorder, capture the client's self-reported symptoms, primary concerns related to substance use, identified triggers, and observable mood or affect during the session to provide a comprehensive clinical picture.

Document client-reported cravings intensity and frequency since the last session.
Note any recent substance use or lapses and circumstances surrounding them.
Identify and describe specific environmental or emotional triggers discussed by the client.
Record observed mood fluctuations, including signs of anxiety, depression, or irritability.
Summarize the client’s expressed motivation or ambivalence toward recovery.

Interventions

Therapeutic techniques and interventions applied during the session

In the Interventions section for substance use disorder, detail the specific therapeutic techniques, clinical observations, and modalities applied during the session to address substance use behaviors and enhance coping strategies.

Specify use of motivational interviewing techniques to explore ambivalence about change.
Describe cognitive-behavioral strategies employed to challenge substance-related thought patterns.
Note implementation of relapse prevention planning and identification of high-risk situations.
Document use of mindfulness or stress reduction exercises introduced during the session.
Record clinical observations of client’s engagement and responsiveness to interventions.

Client Response

Client's reaction to interventions and observable progress

The Client Response section should reflect the client’s reactions to interventions, progress toward treatment goals, any diagnostic reconsiderations, and overall clinical impressions related to substance use disorder.

Evaluate client’s verbal and nonverbal responses to therapeutic interventions.
Assess changes in client’s insight or awareness regarding substance use consequences.
Note any shifts in motivation or readiness to change since previous sessions.
Document client’s reported ability to implement coping strategies outside of sessions.
Consider any emerging symptoms or behaviors that may impact diagnosis or treatment.

Plan Updates

Changes to treatment plan, goals, and next session focus

Plan Updates for substance use disorder should outline next steps in treatment, modifications to the therapy plan, assigned homework, referrals, and scheduling to support sustained recovery and client engagement.

Update treatment goals based on progress or setbacks discussed during the session.
Assign specific homework focused on managing triggers or practicing coping skills.
Schedule or adjust frequency of future sessions to address client needs.
Recommend referrals for medication evaluation, support groups, or specialized services.
Modify relapse prevention strategies or introduce new therapeutic approaches as indicated.