Opioid Pain Medication Follow Up Note

 

 

Diagnosis/location of pain: {FLD:ALLFT47/200}

 

Current therapy is successful/effective for goals:     {FLD:X BOX}Yes  {FLD:X BOX}No

 

Goals met:(e.g. Opioids help improve function and      {FLD:X BOX}Yes  {FLD:X BOX}No

pain by 3 points on pain scale)

 

Therapy/alternatives reviewed with the veteran:        {FLD:X BOX}Yes  {FLD:X BOX}No                             

 

Adverse effects to Current Pain medications            {FLD:X BOX}Yes  {FLD:X BOX}No

               

( GI/mental status/withdrawal etc.):

{FLD:ALLFT47/200}

 

Active Medication List:

|ACTIVE MEDICATIONS|

 

PDMP checks appropriate for prescribed therapy:       {FLD:X BOX}Yes  {FLD:X BOX}No

Opioid Consent on file and patient adherent:          {FLD:X BOX}Yes  {FLD:X BOX}No

UDS appropriate for medication prescribed:            {FLD:X BOX}Yes  {FLD:X BOX}No

 

Safety risk issues/naloxone reviewed with patient.    {FLD:X BOX}Yes  {FLD:X BOX}No

 

STORM or OTTR data was referenced for this note         {FLD:X BOX}Yes  {FLD:X BOX}No

 

In consideration of the above review of subjective and objective data, opioid

therapy is deemed appropriate and the patient requests ongoing therapy. 

 

Patient has been advised of risks and benefits of therapy and acknowledges

receipt of a copy of Taking Opioids Responsibly Pamphlet.

 

VITALS (most recent, as listed in the electronic record):

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

    

            B/P:  |BLOOD PRESSURE|

          Pulse:  |PULSE|

             RR:  |RESPIRATION|

    Temperature:  |TEMPERATURE|

         Height:  |PATIENT HEIGHT|

            BMI:  |BMI|

           Pain:  |PAIN| (0-10 scale)

 

Weight history: (Most recent three weights)

|WEIGHT HISTORY|

 

Focused Physical Exam:

{FLD:X BOX}No acute distress {FLD:X BOX}In acute pain

{FLD:X BOX}Alert, calm, and cooperative  {FLD:X BOX}Lethargic

Heart: {FLD:X BOX}Normal     {FLD:X BOX}Abnormal

Lungs: {FLD:X BOX}Normal     {FLD:X BOX}Abnormal

 

A/P:

1.    Chronic pain : stable on current regimen.

2.    Changes made to current therapy: none {FLD:X BOX}, as noted below {FLD:X BOX}

 

3.    In consideration of the above review of subjective and objective data,

opioid therapy is deemed appropriate and the patient requests ongoing therapy.

4.    Patient has been advised of risks and benefits of therapy and

acknowledges receipt of a copy of Taking Opioids Responsibly Pamphlet.