VA Pharmacy Pain Consult – Inpatient, New Patient (WIP)

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					SUBJECTIVE
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--------------------------    CONSULT DETAILS    ------------------------------




--------------------------------   HPI   --------------------------------------
Briefly, |PATIENT FIRST & LAST NAMES| is a |PATIENT AGE| |PATIENT RACE| 
|PATIENT SEX| with a PMH of: 


Current pain regimen:

PRN analgesic usage:



-------------------------------   PAIN DESCRIPTION   ---------------------------
  Onset
    When did it begin? [text name="variable_1" default=""]
    How long does it typically last? [text name="variable_1" default=""]
    How often does it occur? [text name="variable_1" default=""]
    What were you doing when it started?[text name="variable_1" default=""]

  Provoking / palliating factors
	What brings it on? [text name="variable_1" default=""]
	What makes it worse? [text name="variable_1" default=""]
	What makes it better? [text name="variable_1" default=""]
	
  Quality
	What does it feel like? [text name="variable_1" default=""]

  Region & radiation
	Does your pain radiate? 
	Where does it radiate to? [text name="variable_1" default=""]
	Where does it hurt the most? [text name="variable_1" default=""]
	Where does your pain go from there? [text name="variable_1" default=""]

  Severity
	What is the intensity of the pain?
		Right now? [select name="variable_1" value="10|9|8|7|6|5|4|3|2|1"]
		At its worst? [select name="variable_1" value="10|9|8|7|6|5|4|3|2|1"]
		At its best? [select name="variable_1" value="10|9|8|7|6|5|4|3|2|1"]
	Are there any other symptoms that accompany the pain? [text name="variable_1" default=""]

  Timing & treatment - see below
	
  Understanding
	What do you believe is causing this? [text name="variable_1" default=""]
	How is this affecting your ADLs? [text name="variable_1" default=""]
	How is this affecting your family? [text name="variable_1" default=""]
	Do you have any other concerns? [text name="variable_1" default=""]
 
 
Current pain score:  /10		Goal Pain Score: /10

PAIN INTENSITIES:     Average       Lowest        Worst
Date                    /10          /10           /10 -n/a if first review
Date                    /10          /10           /10  

-------------------------------   PAIN IMPACT    --------------------------------
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?: 

Mobility/Activity:
   Current work: 
   General daily activities:
   Use of mobility aids?: 

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 () 


PEG TOOL                                                        Date: 
--------------------------------------------------------------------------------
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?   /
 ------------------------------------------------/------------------------------
    Average of scores                            /            
--------------------------------------------------------------------------------
 
----------------------------   PAIN TREATMENT HISTORY  -------------------------

Previous Interventional treatment: 
   [ ] Spinal cord stimulator
   [ ] Injection (trigger point, ESI, steroid, etc.)  
   [ ] Surgery 
   [ ] Other: 

Previous Non-pharmacological treatment: 
   [ ] PT/OT 
   [ ] Yoga/Tai Chi 
   [ ] Acupuncture 
   [ ] CBT/Psychotherapy 
   [ ] Mindfulness 
   [ ] MOVE 
   [ ] Heating pad 
   [ ] Cold packs 
   [ ] TENS unit 
   [ ] Other e-stim device 
   [ ] Chiropractor 
   [ ] Others: 

Previous Medication Trials: 
  ANALGESICS/NSAIDS  
   [ ] Aspirin 
   [ ] Acetaminophen
   [ ] Celecoxib
   [ ] Diclofenac
   [ ] Diflunisal
   [ ] Etodolac
   [ ] Fenoprofen
   [ ] Flurbiprofen    
   [ ] Ibuprofen
   [ ] Indomethacin
   [ ] Meloxicam   
   [ ] Naproxen
   [ ] Oxaprozin
   [ ] Piroxicam 
   [ ] Salsalate
   [ ] Sulindac  
   [ ] Tolmetin 

  OPIOIDS  
   [ ] Codeine
   [ ] Fentanyl   
   [ ] Hydrocodone  
   [ ] Hydromorphone
   [ ] Levorphanol 
   [ ] Morphine  
   [ ] Methadone
   [ ] Oxycodone
   [ ] Oxymorphone     
   [ ] Buprenorphine
   [ ] Tramadol
   [ ] Tapentadol   

  TRIPTANS 
   [ ] Almotriptan
   [ ] Eletriptan
   [ ] Rizatriptan   
   [ ] Sumatriptan 
   [ ] Zolmitriptan 
   [ ] Ergotamine/dihydroergotamine 

  TOPICALS 
   [ ] Capsaicin cream/patch 
   [ ] Lidocaine patch/ointment/cream/gel 
   [ ] Diclofenac gel  
   [ ] Menthol/methyl-salicylate cream/patch 

  ANTICONVULSANTS
   [ ] Carbamazepine
   [ ] Gabapentin 
   [ ] Lamotrigine 
   [ ] Levetiracetam
   [ ] Pregabalin  
   [ ] Propranolol   
   [ ] Topiramate   
   [ ] Valproate
   [ ] Verapamil 
        
  MUSCLE RELAXANTS    
   [ ] Baclofen
   [ ] Carisoprodol 
   [ ] Cyclobenzaprine    
   [ ] Metaxalone  
   [ ] Methocarbamol  
   [ ] Tizanidine  

  ANTIDEPRESSANTS 
   [ ] Amitriptyline 
   [ ] Duloxetine 
   [ ] Milnacipran 
   [ ] Nortriptyline 
   [ ] Venlafaxine  

  OTHER
   [ ] Propranolol
   [ ] Verapamil

------------------------------     FUNCTIONING   -------------------------------
Per CPRS chart review:
  Current work: 
  General daily activities: 
  Mobility:
  Sleep: 
  Sleep apnea: 
  Mental health issues: 

------------------------  BRIEF SOCIAL/MILITARY HISTORY ------------------------
Per CPRS chart review:
  |573 G SERVICE CONNECTED|

----------------------------   OPIOID RISK TOOL   ------------------------------
**MALE
  Family history of substance abuse:
  [ ]  3 - Alcohol
  [ ]  3 - Illegal drugs
  [ ]  4 - Prescription drugs
  [ ]  0 - None
  Personal history of substance abuse:
  [ ]  3 - Alcohol
  [ ]  4 - Illegal drugs
  [ ]  5 - Prescription drugs
  [ ]  0 - None
  Age:
  [ ]  0 - Age greater than 45 or less than 16 
  [ ]  1 - age between 16 - 45
  Psychological Disease:
  [ ]  2 - Attention Deficit Disorder, Obsessive Compulsive Disorder, 
           Bipolar, Schizophrenia
  [ ]  1 - Depression
  [ ]  0 - None

**FEMALE
  Family history of substance abuse:
  [ ]  1 - Alcohol
  [ ]  2 - Illegal drugs
  [ ]  4 - Prescription drugs
  [ ]  0 - None
  Personal history of substance abuse:
  [ ]  3 - Alcohol
  [ ]  4 - Illegal drugs
  [ ]  5 - Prescription drugs
  [ ]  0 - None
  Age:
  [ ]  0 - Age greater than 45 or less than 16 
  [ ]  1 - age between 16 - 45
  History of preadolescent sexual abuse:
  [ ]  3 - Yes
  [ ]  0 - No
  Psychological Disease:
  [ ]  2 - Attention Deficit Disorder, Obsessive Compulsive Disorder, 
           Bipolar, Schizophrenia
  [ ]  1 - Depression
  [ ]  0 - None

"?" Indicates not enough information to complete the opioid risk tool with 
available chart information

TOTAL [  ]		Risk Category: 
Low risk (0-3)	Medium risk (4-7)		High risk (score of 8 or more)

The Opioid Risk Tool (ORT) is an office-based assessment designed to predict 
which patients may develop aberrant, drug-related behaviors based on known 
risk factors associated with abuse or addiction. The ORT can either be 
self-administered by the patient at the initial clinic visit or completed by 
the physician as part of the patient interview. 
The ORT displayed excellent discrimination in predicting opioid abuse-related 
behaviors in a single-site study of 185 chronic-pain patients. Of the low-risk 
patients studied, 94% did not demonstrate any aberrant behavior, while in the  
high-risk patients, 91% did display an aberrant behavior. Of the medium risk 
patients, only 28% showed any opioid-related aberrant behavior.
Citation for ORT: Webster LW. Pain Medicine 2005; 6(6): 432-442 
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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|

|REMOTE ACTIVE MEDICATIONS|
 
Medication reconciliation: I have reviewed the outpatient medication list and 
it 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.

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

NFSG ADMISSION HISTORY:
|PREVIOUS ADMISSIONS|

------------------------------   RELATED IMAGING   -----------------------------


-----------------------------   RELATED SURGERIES   ----------------------------
|VA SURGICAL HISTORY|

-------------------------   PERTINENT CONSULTS/NOTES   -------------------------


------------------------------------   PDMP   ----------------------------------


-----------------------   DRUG SCREENING / TESTING   ---------------------------
URINE DRUG TESTING: 
|UA DRUG SCREEN (LAST)|


-------------------------------    VITALS    -----------------------------------
RENAL: Estimated CrCl by Cockcroft-Gault: ~ mL/min based on

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|


WEIGHT TREND
|WEIGHT-LAST 3|

PAIN TREND


-----------------------------------    LABS    ---------------------------------



EKG (if pertinent for QTc prolonging meds)

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

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 opiates can cause 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). 

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.

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				RECOMMENDATIONS/PLAN
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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

- NON-PHARMACOLOGIC


FOLLOW-UP:
 
NOTE: THIS RECORD CONTAINS SENSITIVE PROTECTED HEALTH INFORMATION AND SHOULD BE 
USED ONLY BY QUALIFIED PROVIDERS TO MAKE RELEVENT HEALTH CARE DECISIONS.

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**

Future Appointments:
|FUTURE APPTS|


Time spent:  min
PharmD tool completed