OPIOID & PAIN CARE PLAN
Welcome to the Opioid & Pain Care Plan Tool. To get started, select the type of assessment you would like to complete. Fill out whatever information is relevant to your patient and your note will automatically generate at the bottom of the page. Any sections you leave blank will be excluded from the documentation note.

Once you are finished you can copy the note into your electronic system or print off a copy for your records. You can also generate additional forms to fax the care plan to another health professional by choosing the options in the print section.

Any questions or feedback can be directed to info@qlinicalrx.com.

Choose Assessment(s)


Initial Assessment

Data

Location of Pain

Description of Pain

  • Common Nociceptive Symptoms
  • Common Neuropathic Symptoms
  • Other Symptoms

Etiology of Pain

Onset of pain:
Expected time of resolution:

Goals of Therapy

Current and Past Therapies

Therapy
Daily Dosage
Current Therapy?
Polypharm?
Comments
Current Oral Morphine Equivalents:
Sources

Risk Screening

Use Opioid Risk Tool?
Note: most opioid risk scoring tools have not been validated, but the Opioid Risk Tool is provided as a commonly used tool. It may not encompass all possible risks in patients.
Sex:
Family history of alcohol abuse:
Family history of illegal drug abuse:
Family history of prescription drug abuse:
Personal history of alcohol abuse:
Personal history of illegal drug abuse:
Personal history of prescription drug abuse:
Age of 16 to 45 years old:
History of preadolescent sexual abuse:
Diagnosis of ADD, OCD, bipolar, or schizophrenia:
Diagnosis of depression:
ORT Score = 0 (low risk)
Risk for opioid abuse:

Other Data

Assessment

Indication

Efficacy

Safety & Adherence

Other Assessment Information

Plan

Monitoring & Follow-Up

Monitoring Plan

Follow-Up Plan

Other Comments


Follow-Up Assessment

Data

Efficacy



Adverse Effects

Current Therapy

Therapy
Daily Dosage
Comments

Monitoring for Abuse/Dependence

Other Data

Assessment

Efficacy

Adverse Effects

Abuse & Dependence

Other Assessment Information

Plan

Monitoring & Follow-Up

Monitoring Plan

Follow-Up Plan

Other Comments


Opioid Taper


Opioid Rotation


Two-Way Treatment Agreement


Three-Way Treatment Agreement


Self-Monitoring Preparation: None required; patient may bring own meter in if desired
Meter-Accuracy Preparation: Provide patient with a lab requisition for a random blood glucose. Patient is to take blood glucose meter to lab and take and record reading at the same time as the lab draws their sample.
Hemoglobin A1C Preparation: Provide patient with a lab requisition for an A1C test if there is no recent reading available (3 months for reading above target, 1 year for reading at target).
Hypoglycemia Preparation: None required; patient may bring a list of blood glucose readings for examination if desired.
Injection Technique Preparation: None required; patient may bring in own insulin/liraglutide pen if desired.
Blood Pressure Preparation: None required; patient may bring a list of blood pressure readings for examination if desired.
Cholesterol Preparation: Provide patient with a lab requisition for a fasting lipid panel if no recent readings available (3 months for reading above target, 1 year for reading at target).
Kidney Function Preparation: Provide patient with a lab requisition for serum creatinine and an albumin-creatinine ratio if no recent readings available (3-6 months for unstable nephropathy, 1 year for stable renal function at target).
Coronary Artery Disease Preparation: Provide patient with a lab requisition for an ECG if none available in past year.
Diet Preparation: None required; patient may bring in a food journal if desired.
Exercise Preparation: None required; patient may bring in an exercise journal if desired.
Eye Exam Preparation: None required; patient may bring in past exam results (if available).
Foot/Nerve Exam Preparation: None required; patient may bring in past exam results (if available).
Labs Required for Complete Care Plan: Readings within the past 3 months will be required for A1C, meter calibration, lipid panel, serum creatinine, albumin-creatinine ratio, an ECG.

Documentation Note:

References: