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() presents to the primary care pain clinic today for scheduled renewal and therapeutic monitoring of prescribed opioid analgesic.Primary Care Provider:Team: ___ Diagnosis:Monitor OPIOID Therapy:Available Urine Drug Screen (within past 6 months) ____yes____NoResultsOpioid Treatment Agreement on file___yes___No (have one signed)OPIOID Compliance:__No evidence of poor adherence__Abnormal urine drug screen___UDS positive for non-prescribed drug: ___UDS negative for prescribed drug: __Veteran urine toxicology suggests veteran is not complying with OPIOID Treatment Agreement.__Recurrent reports of lost, stolen, or misplaced drugs__Multiple dose escalations without provider authorization__Obtaining prescription medications from other providers__ Obtaining prescription medications from non-medical sources__Evidence supporting prescription forgery__Using a non prescribed route of opioid administration__Other: OPIOID efficacy/level of analgesia:Pain Scale :Average___ Best___ Worst___ Goal:___Has the pain intensity improved since last pain visit?__Yes__No: Has the QOL improved since last pain visit?__Yes__No:Has patient's functionality (emotional and physical) improved since last visit?__yes:_______________________________________No :_____________________________________Have the goals/ action plan(s) been achieved since last pain visit/medication change?__Yes__No: {comment, which goal, why..}Goal #1:_____________________Goal #2:_____________________Adverse Reaction to the prescribed Opioid:__constipation__nausea and/or vomiting__Itching__Sedation__Mental status changes(confusion__Respiratory depression__Sexual decline__Other:_________________________________________________None (subjective and objective)Current Meds:OPIOID TREATMENT PLAN OF CARE (Check all that apply)__continue same regimen__increase dose to optimize therapy__reduce dose to minimize side effects__change to long acting opioid__add adjuvant__switch to another opioid__Taper off opioid__start/adjust bowel protocol__add anti-nausea__Return to clinic in __weeks for medication renewal/refill__other : ................
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