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.