姑息治疗药物治疗/杂项/有用点语/新会诊住院疼痛管理记录模板
以下是用于住院疼痛管理咨询服务的全面药物管理的示例记录模板。这是作者自己的个人模板，因此其中包含信息，以提醒这位心不在焉的作者询问对其他从业人员来说可能非常明显的问题。请随意使用和编辑此模板。请注意，此记录模板是为 CPRS（VA EMR）创建的，不适合以其原始形式在 Epic、Cerner、Meditech 等中使用。
对于不熟悉 CPRS 的人，条形符号（条形符号 = | |）之间的项目/文本称为 TIU（文本集成实用程序）数据对象，这些数据对象会自动从图表中提取数据。例如，在本模板中遇到的第一个 TIU 数据对象是 |ADMITTING DIAGNOSIS|，当在模板中使用时，它将自动填充当前住院患者的选择性入院诊断。CPRS TIU 数据对象在 VA 设施之间有所不同，尽管有些可能相似。也就是说，如果您想在您所在设施的 CPRS 中使用此模板，某些 TIU 数据对象可能无法正常工作。
NOTE: This is an electronic consult/note performed to aid in the treatment of
the patient and is based upon a review of the chart. Under some circumstances,
this consult may have been requested by internal protocols. The chart was
reviewed in the detail reflected in the note and the recommendations were
based on the available information and the specific request.
================================================================================
SUBJECTIVE
================================================================================
-------------------------- CONSULT DETAILS ------------------------------
----------------------------- ADMISSIONS -------------------------------
ADMITTING DIAGNOSIS: |ADMITTING DIAGNOSIS|
NFSG ADMISSION HISTORY:
|PREVIOUS ADMISSIONS|
---------------------------------- HPI ------------------------------------
|PATIENT FIRST & LAST NAMES| is a |PATIENT AGE| |PATIENT RACE| |PATIENT SEX|
with a PMH of:
Patient's current pain regimen consists of:
-------------------
PATIENT INTERVIEW:
-------------------
Patient seen at bedside today. Patient was amenable to speaking with writer.
Mood: “ “
Affect:
[] appropriate [] inappropriate
[] congruent [] incongruent
[] blunted [] flat [] normal [] intense
[] labile [] even [] expansive
[] broad [] restricted
NON-VERBAL PAIN CUES:
Facial expressions
[] frowning, sad or frightened face
[] grimacing, wincing, eye tightening or closing
[] distorted facial expressions - brow raising/lowering, cheek raising, nose
wrinkling, lip corner pulling
[] rapid blinking.
Vocalisation
[] sighing, groaning, moaning
[] grunting, screaming, calling out
[] aggressive or offensive speech
[] noisy breathing
[] asking for assistance
[] crying out
Body movement
[] tense posture, guarding, rigid
[] fidgeting
[] pacing, rocking or repetitive movements
[] reduced or restricted movement
[] altered gait.
Social interaction
[] aggressive or disruptive behaviour
[] socially inappropriate behaviour
[] decreased social interactions
[] withdrawn.
Autonomic signs
[] pallor
[] sweating
[] rapid breathing (tachypnoea)
[] altered breathing
[] rapid heart rate (tachycardia)
[] hypertension
PAIN DESCRIPTION
Onset
When did it begin?
How long does it typically last?
How often does it occur?
What were you doing when it started?
Provoking / palliating factors
What brings it on?
What makes it worse?
What makes it better?
Quality
What does it feel like?
Region & radiation
Does your pain radiate?
Where does it radiate to?
Where does it hurt the most?
Where does your pain go from there?
Severity
What is the intensity of the pain?
Right now?
At its worst?
Are there any other symptoms that accompany the pain?
Timing & treatment - see below
Understanding
What do you believe is causing this?
How is this affecting your ADLs?
How is this affecting your family?
Do you have any other concerns?
PAIN IMPACT/FUNCTIONING
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?:
If no, complete STOP-BANG in assessment
If yes, compliant with CPAP?
Mobility/Activity:
Current work:
General daily activities:
Use of mobility aids?:
SOCIAL HISTORY
Relationship status:
Living situation:
Does anyone help with medical care?:
Social support:
Physical activity:
Diet:
Alcohol:
Caffeine:
Nicotine:
Cannabis:
Non-prescribed opioids:
Stimulants:
Others:
-------------------
OPIOID MONITORING
-------------------
OMEs over past 24 hours:
If using PRN opioids, how long does each dose last?: ____ hours
If using long-acting opioids, how long does each dose last?: ____ hours
Any scheduled pain medication refusals?: [] No [] Yes:
Current bowel regimen:
Taking bowel regimen as prescribed?: [] Yes [] No:
Date of last documented BM:
Patient normally has ____ BM(s) every _____ days
Nausea/vomiting?: [] Denies [] Endorses: [] unchanged/at patient's baseline
Date of last fall:
Circumstances of last fall:
Dizziness?: [] Denies [] Endorses: [] unchanged/at patient's baseline
Sedation?: [] Denies [] Endorses: [] unchanged/at patient's baseline
Blood pressure: [] WNL [] at patient's baseline [] elevated [] hypotensive
Respiratory rate: [] WNL [] at patient's baseline [] tachypneic [] respiratory depression
-- IF PATIENT ORDERED PATCH --
Skin irritation?: [] Denies [] Endorses: [] unchanged/at patient's baseline
Patch placement: [] writer verified placement, patch was visualized on ______
(area of body)
[] not visualized by writer, but nursing documentation indicates patch remains
on patient, located on ______ (area of body)
Date patch last change?:
------ PATIENT-REPORTED OUTCOMES / CLINICIAN-ADMINISTERED MEASURES ------
Pain catastrophizing = ____ on _____
PROMIS function =
PROMIS pain interference =
PSEQ =
CSSRS =
PHQ-9 =
AUDIT-C =
ORT =
GAD-7 =
HAM-D =
MMSE =
MoCA =
Pain Disability Index =
PEG TOOL
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?
4.) Average of scores
PEG Score Hx
Date: Score:
Date: Score:
Defense and Veterans Pain Rating Scale (DVPRS)
*over a specified time frame
Date Avg Pain* Worst Pain* Lowest Pain*
/10 /10 /10
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 ()
---------------------------- PAIN TREATMENT HISTORY -------------------------
Previous Interventional Treatments:
[ ] Spinal cord stimulator
[ ] Steroid injections
[ ] Trigger point injections
[ ] RFAs
[ ] Surgery
[ ] Other:
Previous Non-pharmacological treatment:
[ ] PT/OT
[ ] Yoga/Tai Chi
[ ] Aquatherapy
[ ] Acupuncture
[ ] Chiropractor
[ ] BFA
[ ] CBT/Psychotherapy ("regular")
[ ] CBT/Psychotherapy (pain-focused)
[ ] Mindfulness
[ ] MOVE! program
[ ] Heating pad
[ ] Cold packs
[ ] TENS unit
[ ] Other e-stim device
[ ] Others:
Previous Medication Trials:
ANALGESICS/NSAIDS
[ ] Aspirin
[ ] Acetaminophen
[ ] Celecoxib
[ ] Diclofenac
[ ] Diflunisal
[ ] Etodolac
[ ] Fenoprofen
[ ] Flurbiprofen
[ ] Ibuprofen
[ ] Indomethacin
[ ] Meloxicam
[ ] Nabumetone
[ ] Naproxen
[ ] Oxaprozin
[ ] Piroxicam
[ ] Salsalate
[ ] Sulindac
[ ] Tolmetin
OPIOIDS
[ ] Codeine
[ ] Fentanyl
[ ] Hydrocodone
[ ] Hydromorphone
[ ] Morphine
[ ] Methadone
[ ] Oxycodone
[ ] Oxymorphone
[ ] Buprenorphine
[ ] Tramadol
[ ] Tapentadol
[ ] Propoxyphene
[ ] Nalbuphine
[ ] Levorphanol
TOPICALS
[ ] Capsaicin cream/patch
[ ] Lidocaine patch/ointment/cream/gel
[ ] Diclofenac gel
[ ] Menthol/methyl-salicylate cream/patch +/- camphor
[ ] Trolamine
ANTICONVULSANTS
[ ] Carbamazepine
[ ] Gabapentin
[ ] Lamotrigine
[ ] Levetiracetam
[ ] Pregabalin
[ ] Topiramate
[ ] Valproate/valproic acid/divalproex
MUSCLE RELAXANTS
[]Baclofen
[]Carisoprodol
[]Cyclobenzaprine
[]Metaxalone
[]Methocarbamol
[]Tizanidine
ANTIDEPRESSANTS
[ ] Amitriptyline
[ ] Desvenlafaxine
[ ] Duloxetine
[ ] Levomilnacipran
[ ] Milnacipran
[ ] Nortriptyline
[ ] Venlafaxine
OTHERS
[ ] Propranolol
[ ] Verapamil
[ ] Clonidine
[ ] Calcitonin
[ ] Bisphosphonate
[ ] Memantine
[ ] Ketamine
--------------------------
TRIPTANS
[ ] Almotriptan
[ ] Eletriptan
[ ] Rizatriptan
[ ] Sumatriptan
[ ] Zolmitriptan
CGRP ANTAGONISTS
[ ] Erenumab (AIMOVIG)
[ ] Fremanezumab (AJOVY)
[ ] Galcanezumab (EMGALITY)
[ ] Eptinezumab (VYEPTI)
[ ] Ubrogepant (UBRELVY)
[ ] Rimegopant (NURTEC)
[ ] Atogepant (QULIPTA)
[ ] Zavegepant (ZAVZPRET)
OTHER HEADACHE MEDS
[ ] Aspirin/Butalbital/Caffeine (FIORINAL, CIII)
[ ] Acetaminophen/Butalbital/Caffeine (FIORICET)
[ ] Ergotamine/dihydroergotamine
================================================================================
OBJECTIVE
================================================================================
-------------------------- 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:
1.) I have:
[] Reviewed entire outpatient medication list
[] Conducted focused review of outpatient medication list with particular
attention paid to pain and pain-related medications
2.) and:
[] the outpatient medication list 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.
[] discrepancies were identified and noted above (see med list)
or
[] unable to perform medication reconciliation
[] med rec not applicable
------------------------------ RELATED IMAGING -----------------------------
----------------------------- RELATED SURGERIES ----------------------------
------------------------- PERTINENT CONSULTS/NOTES -------------------------
------------------------------------ PDMP ----------------------------------
----------------------- DRUG SCREENING / TESTING ---------------------------
URINE DRUG SCREENING:
|UA DRUG SCREEN (LAST)|
DRUG TEST GENERAL (CONFIRMATORY):
ALCOHOL METABOLITES:
CDT-PANEL:
GGT:
------------------------------- 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|
PAIN TREND:
----------------------------------- LABS ---------------------------------
RENAL: Estimated CrCl by Cockcroft-Gault: ~ mL/min based on ___ body weight &
SCr of ____
BASIC METABOLIC PANEL:
ELECTROLYTES:
- Ca
- Mg
- Phos
LIVER PROFILE:
PT & INR:
BLOOD COUNTS:
- WBC
- Plt
- Hgb
- Hct
- MCV
- RDW-SD
A1C%:
VITAMINS:
- Vitamin D
- Vitamin B12:
----------------------------------- EKG ----------------------------------
EKG (if pertinent for QTc prolonging meds)
================================================================================
ASSESSMENT
================================================================================
|PATIENT FIRST & LAST NAMES| is a |PATIENT AGE| |PATIENT RACE| |PATIENT SEX|
with a PMH of:
Patient’s pain is best described as:
[] acute [] acute-on-chronic [] chronic
[] cancer-related [] not cancer-related [] both cancer- and not cancer-related
[] nociceptive [] neuropathic
Current pain regimen includes:
Current limitations to treatment include:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 opioids can increase the perception 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).
------------------ STOP-BANG Screener for OSA -------------------
[ ] Do you snore loudly (louder than talking or loud enough to be heard through
closed doors)?
[ ] Do you often feel tired, fatigued, or sleepy during the day?
[ ] Has anyone ever observed you stop breathing during your sleep?
[ ] Do you have or are you being treated for high blood pressure?
[ ] BMI > 35kg/m^2
[ ] Age > 50
[ ] Neck circumference > 16 in (40cm)
[ ] Male gender
Each YES response = 1 point
Low risk: 0 - 2 points Moderate risk: 3 - 4 points High risk: 5 – 8
High sensitivity (93%-100%) noted when using STOP-Bang questionnaire to detect
moderate to severe and severe sleep disordered breathing in surgical population
patients however low specificity noted at original cut-off of 3. Recent studies
indicate total scores of 5-8 have higher specificity.
================================================================================
RECOMMENDATIONS
================================================================================
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
- OTHER
- NON-PHARMACOLOGIC
> Anti-inflammatory diet
> PT/OT
> Pain psychology
> Mindfulness
> Heating pads / packs
> Cold packs
> Stretches / guided exercises
> TENS unit
> Chiropractor
> MOVE! program
> Aquatherapy
> CPAP for OSA
- BOWEL REGIMEN
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**
================================================================================
EDUCATION
================================================================================
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.
FUTURE APPOINTMENTS
|FUTURE APPTS|
Follow-up: will continue to follow peripherally until pain is stabilized
Time spent: 90 min
PharmD tool completed
------------------------------
ABBREVIATIONS
------------------------------
OMEs = oral morphine equivalents
CSSRS = Columbia Suicide Severity Rating Scale
PEG = The Pain, Enjoyment of Life and General Activity
PHQ = Patient Health Questionnaire
AUDIT-C = Alcohol Use Disorders Identification Test
PSEQ = Pain Self-Efficacy Questionnaire
ORT = Opioid Risk Tool
GAD-7 = General Anxiety Disorder
HAM-D = Hamilton Depression Rating Scale