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

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.

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=================================================================== SUBJECTIVE

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

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

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

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) Date      Avg Pain*      Worst Pain*       Lowest Pain* /10           /10               /10
 * over a specified time frame

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

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=================================================================== OBJECTIVE

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=================================================================== --   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|

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
 * REMOTE ACTIVE 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)

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=================================================================== ASSESSMENT

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

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.

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=================================================================== RECOMMENDATIONS

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=================================================================== 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**

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=================================================================== EDUCATION

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=================================================================== 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