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Palliative Pharmacotherapy/Miscellaneous/Helpful Dot Phrases/New Consult Inpatient Pain Management Note Template

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The following is an EXAMPLE note template that could be used for comprehensive medication management for an inpatient pain management consult service. This is the author's own personal template and therefore has information in place to remind this scatterbrained author to ask questions that may be very obvious to other practitioners. Please feel free to use and edit this template as you wish. Beware that this note template has been created for CPRS (VA EMR) and is not suitable in its raw form for use in Epic, Cerner, Meditech, etc.

For those unfamiliar with CPRS, the items / text between bars (bars = | |) are called TIU (text integration utility) data objects and these pull data from the chart automatically. For example, in this template the first TIU data object encountered is |ADMITTING DIAGNOSIS|, which when used in a template will automatically populate with the selected patient's admitting diagnosis for the current inpatient admission. CPRS TIU data objects vary across VA facilities, though some may be similar. That is to say - if you would like to use this template within CPRS at your facility, some of the TIU data objects may not work properly. 

NOTE: This is an electronic consult/note performed to aid in the treatment of 
the patient and is based upon a review of the chart. Under some circumstances, 
this consult may have been requested by internal protocols. The chart was 
reviewed in the detail reflected in the note and the recommendations were 
based on the available information and the specific request. 

================================================================================
SUBJECTIVE
================================================================================
--------------------------    CONSULT DETAILS    ------------------------------

-----------------------------     ADMISSIONS     -------------------------------
ADMITTING DIAGNOSIS: |ADMITTING DIAGNOSIS|

NFSG ADMISSION HISTORY:
|PREVIOUS ADMISSIONS|
----------------------------------   HPI   ------------------------------------
|PATIENT FIRST & LAST NAMES| is a |PATIENT AGE| |PATIENT RACE| |PATIENT SEX| 
with a PMH of: 

Patient's current pain regimen consists of: 

-------------------
PATIENT INTERVIEW:
-------------------
Patient seen at bedside today. Patient was amenable to speaking with writer. 

Mood: “ “
Affect:
[] appropriate  [] inappropriate 
[] congruent  [] incongruent 
[] blunted  [] flat  [] normal  [] intense
[] labile  [] even  [] expansive 
[] broad  [] restricted 


NON-VERBAL PAIN CUES:
Facial expressions
[] frowning, sad or frightened face
[] grimacing, wincing, eye tightening or closing
[] distorted facial expressions - brow raising/lowering, cheek raising, nose 
wrinkling, lip corner pulling
[] rapid blinking.
Vocalisation
[] sighing, groaning, moaning
[] grunting, screaming, calling out
[] aggressive or offensive speech
[] noisy breathing
[] asking for assistance
[] crying out
Body movement
[] tense posture, guarding, rigid
[] fidgeting
[] pacing, rocking or repetitive movements
[] reduced or restricted movement
[] altered gait.
Social interaction
[] aggressive or disruptive behaviour
[] socially inappropriate behaviour
[] decreased social interactions
[] withdrawn.
Autonomic signs
[] pallor
[] sweating
[] rapid breathing (tachypnoea)
[] altered breathing
[] rapid heart rate (tachycardia)
[] hypertension


PAIN DESCRIPTION
  Onset
	When did it begin?
	How long does it typically last?
	How often does it occur?
	What were you doing when it started?

  Provoking / palliating factors
	What brings it on?
	What makes it worse?
	What makes it better?
	
  Quality
	What does it feel like?

  Region & radiation
	Does your pain radiate?
	Where does it radiate to?
	Where does it hurt the most?
	Where does your pain go from there?

  Severity
	What is the intensity of the pain?
		Right now?
		At its worst?
	Are there any other symptoms that accompany the pain?

  Timing & treatment - see below
	
  Understanding
	What do you believe is causing this?
	How is this affecting your ADLs?
	How is this affecting your family?
	Do you have any other concerns?

PAIN IMPACT/FUNCTIONING
  Sleep:
     Any trouble falling asleep and/or staying asleep?:
     Do you wake up during the night due to pain?: 
     Is your sleep restful?: 
     Number of hours per night on average:
     Diagnosis of sleep apnea?: 
         If no, complete STOP-BANG in assessment
         If yes, compliant with CPAP?

  Mobility/Activity:
     Current work: 
     General daily activities:
     Use of mobility aids?: 

SOCIAL HISTORY
Relationship status:
Living situation:
Does anyone help with medical care?:
Social support:
Physical activity:
Diet:
Alcohol:
Caffeine:
Nicotine:
Cannabis:
Non-prescribed opioids:
Stimulants:
Others:

-------------------
OPIOID MONITORING
-------------------

OMEs over past 24 hours:
If using PRN opioids, how long does each dose last?: ____ hours
If using long-acting opioids, how long does each dose last?: ____ hours
Any scheduled pain medication refusals?: [] No  [] Yes: 

Current bowel regimen: 

Taking bowel regimen as prescribed?: [] Yes  [] No: 
Date of last documented BM:
Patient normally has ____ BM(s) every _____ days
Nausea/vomiting?: [] Denies  [] Endorses:  [] unchanged/at patient's baseline

Date of last fall:
Circumstances of last fall:
Dizziness?: [] Denies  [] Endorses:  [] unchanged/at patient's baseline
Sedation?: [] Denies  [] Endorses:  [] unchanged/at patient's baseline 

Blood pressure:   [] WNL [] at patient's baseline [] elevated [] hypotensive
Respiratory rate: [] WNL [] at patient's baseline [] tachypneic [] respiratory depression


-- IF PATIENT ORDERED PATCH --

Skin irritation?:  [] Denies  [] Endorses:  [] unchanged/at patient's baseline 
Patch placement: [] writer verified placement, patch was visualized on ______ 
                                                                (area of body)
[] not visualized by writer, but nursing documentation indicates patch remains 
   on patient, located on ______ (area of body)
Date patch last change?:

------    PATIENT-REPORTED OUTCOMES / CLINICIAN-ADMINISTERED MEASURES    ------
Pain catastrophizing = ____ on _____
PROMIS function = 
PROMIS pain interference = 
PSEQ = 
CSSRS = 
PHQ-9 = 
AUDIT-C = 
ORT = 
GAD-7 = 
HAM-D = 
MMSE = 
MoCA = 
Pain Disability Index = 

PEG TOOL                                                       
1.) Average pain score (see above) 
2.) On scale of 0 (no interference) through 10 (extreme/frequent interference), 
    which number best describes how pain has interfered with your enjoyment of 
    life during the past week?
3.) On a scale of 0 (no interference) through 10 (extreme/frequent 
    interference), which number best describes how pain has interfered with your 
    general activity during the past week?   
4.) Average of scores       
 
PEG Score Hx
   Date:		Score:
   Date:		Score:  

Defense and Veterans Pain Rating Scale (DVPRS)
*over a specified time frame
Date       Avg Pain*      Worst Pain*       Lowest Pain*
           /10            /10               /10

Functional Goal(s):
What would you like to do that your pain is currently preventing you from doing?
Date:     Improved ()  Same ()  Worse ()  
Date:     Improved ()  Same ()  Worse () 
----------------------------   PAIN TREATMENT HISTORY  -------------------------

Previous Interventional Treatments: 
   [ ] Spinal cord stimulator
   [ ] Steroid injections 
   [ ] Trigger point injections
   [ ] RFAs
   [ ] Surgery 
   [ ] Other: 

Previous Non-pharmacological treatment: 
   [ ] PT/OT 
   [ ] Yoga/Tai Chi 
   [ ] Aquatherapy
   [ ] Acupuncture 
   [ ] Chiropractor 
   [ ] BFA 
   [ ] CBT/Psychotherapy ("regular")
   [ ] CBT/Psychotherapy (pain-focused)
   [ ] Mindfulness 
   [ ] MOVE! program 
   [ ] Heating pad 
   [ ] Cold packs 
   [ ] TENS unit 
   [ ] Other e-stim device 
   [ ] Others: 

Previous Medication Trials: 
  ANALGESICS/NSAIDS  
   [ ] Aspirin 
   [ ] Acetaminophen
   [ ] Celecoxib
   [ ] Diclofenac
   [ ] Diflunisal
   [ ] Etodolac
   [ ] Fenoprofen
   [ ] Flurbiprofen    
   [ ] Ibuprofen
   [ ] Indomethacin
   [ ] Meloxicam
   [ ] Nabumetone   
   [ ] Naproxen
   [ ] Oxaprozin
   [ ] Piroxicam 
   [ ] Salsalate
   [ ] Sulindac  
   [ ] Tolmetin 

  OPIOIDS  
   [ ] Codeine
   [ ] Fentanyl   
   [ ] Hydrocodone  
   [ ] Hydromorphone
   [ ] Morphine  
   [ ] Methadone
   [ ] Oxycodone
   [ ] Oxymorphone     
   [ ] Buprenorphine
   [ ] Tramadol
   [ ] Tapentadol
   [ ] Propoxyphene
   [ ] Nalbuphine
   [ ] Levorphanol   

  TOPICALS 
   [ ] Capsaicin cream/patch 
   [ ] Lidocaine patch/ointment/cream/gel 
   [ ] Diclofenac gel  
   [ ] Menthol/methyl-salicylate cream/patch +/- camphor
   [ ] Trolamine

  ANTICONVULSANTS
   [ ] Carbamazepine
   [ ] Gabapentin 
   [ ] Lamotrigine 
   [ ] Levetiracetam
   [ ] Pregabalin  
   [ ] Topiramate   
   [ ] Valproate/valproic acid/divalproex
        
  MUSCLE RELAXANTS    
   []Baclofen
   []Carisoprodol 
   []Cyclobenzaprine    
   []Metaxalone  
   []Methocarbamol  
   []Tizanidine  

  ANTIDEPRESSANTS 
   [ ] Amitriptyline
   [ ] Desvenlafaxine 
   [ ] Duloxetine 
   [ ] Levomilnacipran
   [ ] Milnacipran 
   [ ] Nortriptyline 
   [ ] Venlafaxine  

  OTHERS
   [ ] Propranolol
   [ ] Verapamil
   [ ] Clonidine
   [ ] Calcitonin
   [ ] Bisphosphonate
   [ ] Memantine
   [ ] Ketamine

--------------------------

  TRIPTANS 
   [ ] Almotriptan
   [ ] Eletriptan
   [ ] Rizatriptan   
   [ ] Sumatriptan 
   [ ] Zolmitriptan 

  CGRP ANTAGONISTS
   [ ] Erenumab (AIMOVIG)
   [ ] Fremanezumab (AJOVY)
   [ ] Galcanezumab (EMGALITY)
   [ ] Eptinezumab (VYEPTI)
   [ ] Ubrogepant (UBRELVY)
   [ ] Rimegopant (NURTEC)
   [ ] Atogepant (QULIPTA)
   [ ] Zavegepant (ZAVZPRET)

  OTHER HEADACHE MEDS
   [ ] Aspirin/Butalbital/Caffeine (FIORINAL, CIII)
   [ ] Acetaminophen/Butalbital/Caffeine (FIORICET)
   [ ] Ergotamine/dihydroergotamine

================================================================================
OBJECTIVE
================================================================================
--------------------------    ACTIVE PROBLEMS PER CPRS   -----------------------
|ACTIVE PROBLEMS (1 COLUMN)|

-------------------------   MEDICATION PROFILE   -------------------------------
ALLERGIES/ADRs:  |ALLERGIES/ADR|
REMOTE ALLERGY/ADR: |RART|

INPATIENT MEDICATION REVIEW
|DETAILED RECENT MEDS|

OUTPATIENT MEDICATION REVIEW
|ACTIVE OPT MEDS|

RECENTLY EXPIRED OP MEDS:
|RECENTLY EXP OP MEDS|

|REMOTE ACTIVE MEDICATIONS|
 
MEDICATION RECONCILIATION:
1.) I have:
      [] Reviewed entire outpatient medication list
      [] Conducted focused review of outpatient medication list with particular 
         attention paid to pain and pain-related medications

2.) and:
      [] the outpatient medication list accurately reflects the medications that 
         patient is currently taking, including any that may be provided from 
         non-VA sources, over the counter medications, nutritional or other 
         supplements. Medications reviewed to identify and address duplicity or 
         polypharmacy issues.
      [] discrepancies were identified and noted above (see med list)

or 
[] unable to perform medication reconciliation
[] med rec not applicable 
------------------------------   RELATED IMAGING   -----------------------------


-----------------------------   RELATED SURGERIES   ----------------------------


-------------------------   PERTINENT CONSULTS/NOTES   -------------------------


------------------------------------   PDMP   ----------------------------------


-----------------------   DRUG SCREENING / TESTING   ---------------------------
URINE DRUG SCREENING: 
|UA DRUG SCREEN (LAST)|

DRUG TEST GENERAL (CONFIRMATORY):

ALCOHOL METABOLITES:

CDT-PANEL:

GGT:

-------------------------------    VITALS    -----------------------------------
Age: |PATIENT AGE| y/o; |PATIENT SEX|
Weight |PATIENT WEIGHT|
Height |PATIENT HEIGHT|
BMI: |BMI|
IBW: |IBW|
SCr   |CREATININE-G,J,D|
BP: |BLOOD PRESSURE|
Pulse: |PULSE|
Temp: |TEMPERATURE|
RR: |RESPIRATION|
Pain: |PAIN|

PAIN TREND:


-----------------------------------    LABS    ---------------------------------
RENAL: Estimated CrCl by Cockcroft-Gault: ~ mL/min based on ___ body weight & 
SCr of ____

BASIC METABOLIC PANEL:

ELECTROLYTES:
- Ca
- Mg
- Phos

LIVER PROFILE:

PT & INR:

BLOOD COUNTS:
- WBC
- Plt
- Hgb
- Hct
- MCV
- RDW-SD

A1C%:

VITAMINS:
- Vitamin D
- Vitamin B12:


-----------------------------------    EKG    ----------------------------------
EKG (if pertinent for QTc prolonging meds)

================================================================================
ASSESSMENT
================================================================================
|PATIENT FIRST & LAST NAMES| is a |PATIENT AGE| |PATIENT RACE| |PATIENT SEX| 
with a PMH of: 


Patient’s pain is best described as:
[] acute   [] acute-on-chronic  [] chronic
[] cancer-related [] not cancer-related [] both cancer- and not cancer-related
[] nociceptive  [] neuropathic

Current pain regimen includes:

Current limitations to treatment include:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

There is evidence to support weight loss, smoking cessation, PT, exercise, Pain 
psychology, and non-opioid medications in treating chronic non-cancer pain.

The use of chronic opioids in non-cancer pain is not recommended. Long-term 
opioid use or escalation can induce a state of opioid-induced hyperalgesia in 
which the opioids can increase the perception pain. Additional long-term effects include 
tolerance, physical dependence, immune dysfunction and hypogonadism. As patients 
age, issues like cognition, bowel function, sedation, respiratory suppression 
and falls can become more problematic. Additional situations that increase the 
risk of opioids include opioid dose, concomitant benzodiazepines, and patient 
comorbidities that can complicate pain management (medical: COPD, OSA, obesity; 
mental health: depression, PTSD, insomnia; substance use disorder: alcohol, 
opioids, tobacco). Functioning will not improve without addressing other 
comorbidities that can worsen pain and/or pain perception or increase the 
risks of opioid therapy. For these reasons, pain conditions are most 
appropriately treated by non-opioid adjuvant medications that have opioid 
sparing characteristics.

The pain condition this veteran suffers from is best treated with a 
multidisciplinary approach. This involves an increase in physical activity to 
prevent de-conditioning and worsening of the pain cycle, psychological 
counseling (formal and/or informal) to address the co-morbid psychological 
effects of pain, as well as the use of non-opioid pain medications and 
interventional strategies. A carefully designed active treatment plan has 
a greater impact on pain, mobility, function and quality of life. There is 
emerging evidence that passive treatment strategies can harm patients by 
exacerbating fears and anxiety about being physically active when in pain,
which can prolong recovery. Goals of therapy are objective improvement in 
function and realistic reduction in pain reports (30% improvement). 

------------------    STOP-BANG Screener for OSA   -------------------
[ ] Do you snore loudly (louder than talking or loud enough to be heard through 
    closed doors)?
[ ] Do you often feel tired, fatigued, or sleepy during the day?
[ ] Has anyone ever observed you stop breathing during your sleep?
[ ] Do you have or are you being treated for high blood pressure?
[ ] BMI > 35kg/m^2
[ ] Age > 50
[ ] Neck circumference > 16 in (40cm)
[ ] Male gender

Each YES response = 1 point
Low risk: 0 - 2 points		Moderate risk: 3 - 4 points		High risk: 5 – 8

High sensitivity (93%-100%) noted when using STOP-Bang questionnaire to detect 
moderate to severe and severe sleep disordered breathing in surgical population 
patients however low specificity noted at original cut-off of 3. Recent studies 
indicate total scores of 5-8 have higher specificity.

================================================================================
RECOMMENDATIONS
================================================================================
The provider of record for the controlled substance must document in the medical 
record the need and intended indication for the controlled substance being 
prescribed. The provider of record for the controlled substance should either 
include the necessary documentation in their own progress note or provide such 
information in an addendum to the CPP’s note

- OPIOIDS

- NON-OPIOID ANALGESICS

- OTHER

- NON-PHARMACOLOGIC
> Anti-inflammatory diet
> PT/OT
> Pain psychology
> Mindfulness
> Heating pads / packs
> Cold packs
> Stretches / guided exercises
> TENS unit
> Chiropractor
> MOVE! program
> Aquatherapy
> CPAP for OSA

- BOWEL REGIMEN
 

Implementation of recommendations is left to the provider's discretion. Thank 
you for the consult. **Please re-consult or contact our service if there are any 
further questions**

================================================================================
EDUCATION
================================================================================
Rationale for use, dosing instructions, side effects, and precautions of 
medications reviewed with patient in detail. Patient expressed understanding of 
the information provided, agreement with our plan of care, and was instructed 
to call in the event of any drug-related problem.

FUTURE APPOINTMENTS
|FUTURE APPTS|

Follow-up: will continue to follow peripherally until pain is stabilized

Time spent:  90 min
PharmD tool completed


------------------------------
       ABBREVIATIONS
------------------------------
OMEs = oral morphine equivalents
CSSRS = Columbia Suicide Severity Rating Scale
PEG = The Pain, Enjoyment of Life and General Activity 
PHQ = Patient Health Questionnaire 
AUDIT-C = Alcohol Use Disorders Identification Test 
PSEQ = Pain Self-Efficacy Questionnaire
ORT = Opioid Risk Tool
GAD-7 = General Anxiety Disorder
HAM-D = Hamilton Depression Rating Scale
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