Controlled Substance Note

[comment memo="History" memo_size="large" memo_style="bold"]

The [select value="patient|family|power of attorney|facility staff"] request a prescription for [text default="medication name"].

This is a [select value="new|currently prescribed"] medication.
The primary indication for the medicine is [checkbox name="Indication" value="pain|anxiety|seizure prevention"]

The patient's current symptoms include:
[checkbox name="Symptoms" value="chronic low back pain|chronic knee pain|chronic hip pain|chronic neck pain|chronic pain in multiple areas|pain related to cancer|fibromyalgia|anxiety|difficulty falling asleep|seizures"] 

The impact on the patient's life includes of this medicine are:
[checkbox value="inability to complete activities of daily living |inability to sleep|inability to be comfortable while at rest|inability to be comfortable while active|inability to participate in physical and/or occupational therapy|inability to enjoy his/her life|frequent seizures unresponsive to alternative treatments"]

The prescription drug monitoring program (PDMP) report was recently run and I reviewed it today. 
[checkbox name="PDMP" value="No concerning history of prescriptions was identified.|Records from previous prescribers of controlled substances have been requested. |I have concerns based on my review"]  
[conditional field="PDMP" condition="(PDMP).is('I have concerns based on my review')"] [text size=30 default="concerns"][/conditional]

The patient has tried the following alternatives without adequate relief of their symptoms:
[checkbox value="Acetaminophen|NSAIDs|Topical creams|Physical therapy|Corticosteroid injections|Surgical treatment|Gabapentinoids (such as gabapentin and Lyrica)|SSRI|SNRI (such as Cymbalta)|Hydroxyzine|Behavioral therapy|Meditation"]

[conditional field="Indication" condition="(Indication).is('pain')"] 
On a scale from 1 to 10, the patient's pain in the past week is: [text size=30 default="number"]
On a scale from 1 to 10, the degree that the patient’s pain has interfered with their enjoyment of life is: [text size=30 default="number"]
On a scale from 1 to 10, the degree that the patient’s pain has interfered with their general activity is: [text size=30 default="number"]
[/conditional]

[checkbox value="The patient denies any personal history of a substance use disorder|The patient denies any family history of a substance use disorder|The patient has a history of a substance use disorder|The patient has a family history of a substance use disorder"]

In the past year, have you used any of the following:

[select name="Q1" value="no=0|YES=1"] <-- In the past year, have you had more than 5 alcoholic drinks per day (for men) or more than 4 alcoholic drinks per day (for women)?
[select name="Q2" value="no=0|YES=1"] <-- In the past year, have you used prescription drugs for non-medical reasons?
[select name="Q3" value="no=0|YES=1"] <-- In the past year, have you used street drugs?
Interpretation --> [name="Score Results" calc value="score=(Q1)+(Q2)+(Q3)+(Q4);score>0?'POSITIVE Screen for Alcohol or Drug Addiction - One positive response to any question suggests the need for closer assessment. ':'NEGATIVE screen for Alcohol or Drug Addiction.'" memo="interpretation"]

The patient has the following conditions that place him/her at increased risk of an unintentional overdose:
[checkbox value="obstructive sleep apnea|cirrhosis|chronic kidney disease|heart failure|COPD"]


[comment memo="Plan" memo_size="large" memo_style="bold"]

I advised the patient that all prescriptions for controlled substances should be managed by our office. I advised the patient that we would review the PDMP and if the patient is found to be in violation of this agreement, we will no longer prescribe controlled substances.

[checkbox value="We reviewed the risks of opioid therapy, including addiction, chemical dependence, unintentional overdose of the patient or a visitor, respiratory depression, sexual dysfunction, hyperalgesia, and death.  I have encouraged the patient to keep naloxone (Naltrexone) on hand in case of an accidental overdose.|We reviewed the risks of chronic benzodiazepine therapy, including addiction, chemical dependence, unintentional overdose by the patient or a visitor, respiratory depression, cognitive decline, and death."]  

[checkbox value="The patient is at increased risk of an accidental overdose because of his/her history of chronic medical conditions.|The patient is at increased risk of an accidental overdose because of high doses of opioids.|The patient is at increased risk of an accidental overdose because of his/her need for both opioids and benzodiazepines.|The patient is at average risk of an accidental overdose."]  

[checkbox value="There are no signs of an active substance use disorder.|I suspect the patient has an untreated substance use disorder."]

[checkbox value="At this time, the patient and I agree that the benefits of using the controlled substance therapy outweigh the risks.  A controlled substance agreement was signed today and is in the attachment section of the chart. Prescription was provided as documented below.|At this time, the patient and I agree that the risks of continuing the controlled substance outweigh the benefits and we will begin a gradual taper. A controlled substance agreement was signed today and is in the attachment section of the chart. Prescription was provided as documented below."]

The current MME is [http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm].
History

The request a prescription for .

This is a medication.
The primary indication for the medicine is

The patient's current symptoms include:


The impact on the patient's life includes of this medicine are:


The prescription drug monitoring program (PDMP) report was recently run and I reviewed it today.



The patient has tried the following alternatives without adequate relief of their symptoms:






In the past year, have you used any of the following:

<-- In the past year, have you had more than 5 alcoholic drinks per day (for men) or more than 4 alcoholic drinks per day (for women)?
<-- In the past year, have you used prescription drugs for non-medical reasons?
<-- In the past year, have you used street drugs?
Interpretation --> [name="Score Results" calc value="score=(Q1)+(Q2)+(Q3)+(Q4);score>0?'POSITIVE Screen for Alcohol or Drug Addiction - One positive response to any question suggests the need for closer assessment. ':'NEGATIVE screen for Alcohol or Drug Addiction.'" memo="interpretation"]

The patient has the following conditions that place him/her at increased risk of an unintentional overdose:



Plan

I advised the patient that all prescriptions for controlled substances should be managed by our office. I advised the patient that we would review the PDMP and if the patient is found to be in violation of this agreement, we will no longer prescribe controlled substances.









The current MME is [http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm].

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.76, 25 form elements, 243 boilerplate words, 5 text boxes, 11 checkboxes, 5 drop downs, 2 comments, 2 conditionals, 64 total clicks
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