Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Follow-up for chronic pain management with opioids
Assessment of pain control and opioid side effects
Discussion of alternative pain management strategies
Chief Complaint:
pen_spark
(Focus on pain)
Location, severity (use a pain scale), and character (e.g., aching,
burning) of pain.
Impact of pain on daily activities (sleep, work, mood).
History of Present Illness:
Underlying cause of pain (if known).
Duration and course of pain.
Previous treatments for pain (medications, procedures, therapies).
Current opioid medication regimen (type, dose, frequency, route of
administration).
Response to current opioid regimen (pain control, side effects).
Past Medical History:
Medical conditions that may contribute to pain or affect opioid
metabolism (e.g., kidney disease, sleep apnea).
History of mental health conditions (e.g., depression, anxiety)
that may
impact pain perception.
History of substance use disorders (important for risk assessment).
Social History:
Occupational factors that may contribute to pain (e.g., manual labor).
Social support system (positive and negative influences on pain
management).
Physical Exam:
General examination: Assess vital signs and overall health status.
Focused physical examination: Evaluate the source of pain and
functional limitations.
Assessment:
Chronic pain: Diagnosed based on history and physical examination.
Pain severity: Consider using a pain scale to quantify pain intensity.
Response to opioid therapy: Evaluate pain control achieved and presence of side effects (e.g., constipation, drowsiness, sedation).
Risk factors for opioid misuse: Consider history of substance use disorders, mental health conditions, and social support.
Plan:
Pain management goals: Set realistic goals for pain control and
functional improvement.
Opioid optimization: Consider adjusting opioid dose or frequency
based on pain control and side effects.
Alternative pain management strategies: Discuss and encourage
non-opioid options (e.g., physical therapy, massage therapy, acupuncture,
cognitive behavioral therapy for chronic pain).
Addressing risk factors for misuse: Develop strategies to
mitigate risk of opioid misuse (e.g., medication contracts, monitoring systems).
Follow-up: Schedule regular follow-up appointments to monitor
pain control, adjust treatment as needed, and address any concerns.
Patient education: Educate the patient about pain management
strategies, safe opioid use, and potential side effects.
Discussion Points:
Risks and benefits of continued opioid use.
Importance of using opioids as prescribed and avoiding dose escalation.
Availability of naloxone (an opioid antagonist) to reverse
overdose in case of emergency.
Additional Notes:
Document adherence to pain management plan.
Consider using urine drug screens to monitor for illicit substance use.
Involve pain specialists or addiction medicine specialists as needed
for complex cases.
Disclaimer: This template is a guide and may need to be adapted
depending on the specific patient and their individual needs. It is
recommended to consult with current guidelines for chronic pain management
and opioid prescribing.