Acute Pain Service Consult Note

Date and time of service: [Date/time of consult]

Patient location: [Unit/room] — [Postoperative day number / Day of surgery]

Requesting service and clinician: [Requesting service and clinician name] (If not documented, state that clarification was sought.)

Reason for consult: [Brief reason for consultation]

Sources of information: [Patient / caregiver / chart / anesthesia record / MAR / PDMP] (List all sources used. If PDMP reviewed, include date and key finding.)

Consult Summary

[4–6 line high-yield summary including: surgery/procedure and date; principal pain drivers/mechanisms; current analgesic modalities in use; key risk factors (opioid tolerance, OUD, OSA, sedatives, renal/hepatic impairment); one-sentence plan headline.]

History of Present Illness

Chief complaint: [Patient's words when obtainable] (If unobtainable, state why and identify collateral sources.)

Surgical/anesthetic context: [Procedure name] on [Date]; [Postoperative day]; [Surgical approach]; [Intraoperative regional/neuraxial techniques performed, if any].

Pain characterization: [Location and radiation]; [Intensity using validated scale]; [Quality: nociceptive / neuropathic / spasm]; [Timing and breakthrough pattern]; [Aggravating/relieving factors]; [Functional impact: breathing, mobility, sleep, oral intake]; [Associated symptoms: nausea, pruritus, constipation, urinary retention, sedation, dysphoria].

Response to current regimen: [What has helped]; [What has not helped]; [Adverse effects]; [Barriers to use or access].

Chronic pain/long-term opioids: [Baseline pain conditions]; [Home analgesics with doses/schedules]; [Prior effective regimens]; [Prior adverse reactions to analgesics or regional techniques]. (Include if applicable.)

Opioid tolerance status: [Opioid naïve / Opioid exposed / Opioid tolerant] — [Supporting rationale: home MME, duration, recent use].

OUD status: [Present / Suspected / None] — [Supporting information]. (Include if applicable.)

MOUD: [Medication: buprenorphine / methadone / naltrexone], [Dose], [Schedule], [Last dose date/time]. (If unknown, state: Information pending — confirm MOUD details prior to opioid changes. Include if applicable.)

Sedation-risk co-medications: [Benzodiazepines / Gabapentinoids / Z-drugs] with [doses/schedules]. (Include if present.)

Patient goals: [Stated functional goals if discussed].

Limitations to history: [Delirium / Intubation / Language barrier / Other] — [Collateral sources used]. (Include if applicable.)

Pertinent History

(Include only analgesia-relevant conditions. For safety-critical unknowns, explicitly state information is pending.)

• [Respiratory risk factors: OSA with device compliance, COPD, baseline O2 requirement]
• [Renal dysfunction with recent creatinine/eGFR]
• [Hepatic dysfunction with synthetic function if relevant]
• [Coagulopathy/anticoagulation: agent, dose, last dose time] (If unknown: Anticoagulation status pending — verify before neuraxial/regional intervention.)
• [Delirium risk or psychiatric history relevant to ketamine]
• [Allergies/intolerances — distinguish true allergy vs adverse effect] (If unknown: Allergy history pending — confirm before ordering new agents.)
• [Baseline neurologic deficits pertinent to regional planning]

Objective

Vitals: [BP, HR, RR, Temp, SpO2] — [Oxygen delivery mode and rate]

General/Mental Status: [Appearance]; [Level of arousal]; [Sedation score using institutional scale].

Respiratory: [Work of breathing]; [Rate/pattern]; [Airway concerns].

Pain Exam: [Tenderness/guarding/splinting at sites]; [Signs of neuropathic pain/allodynia if present].

Functional Status: [Ability to cough/deep breathe]; [Participation in PT/ambulation].

GI: [Nausea/vomiting]; [Bowel function]. (Include if relevant to opioid effects.)

Neurologic: [Motor/sensory exam pertinent to neuraxial/regional or neuropathic pain]. (Include if applicable.)

Lines/Catheters: [Epidural level and site assessment]; [Peripheral nerve catheter site]; [Chest tubes/drains relevant to pain]. (Include if applicable.)

Relevant Labs: [Renal function, coagulation, QTc, other decision-relevant results]. (Include only if pertinent to analgesic decisions.)

Current Analgesia

Scheduled Nonopioids: [Acetaminophen with total daily dose]; [NSAID/COX-2 with renal/GI considerations]; [Other adjuvants with doses].

PRN Opioids: [Drug], [Route], [Dose], [Frequency].

PCA: [Drug], [Concentration], [Demand dose], [Lockout], [Basal rate if any]. (Include if present.)

Neuraxial: [Epidural level], [Solution], [Rate], [PCEA settings], [Dermatomal coverage and motor block]. (Include if present.)

Peripheral Catheter: [Block type], [Infusion solution/rate], [Clinical effect]. (Include if present.)

Adjunct Infusions: [Ketamine / Lidocaine / Dexmedetomidine] — [Dose/rate], [Monitoring], [Contraindications screened]. (Include if present.)

Adverse Effect Management: [Bowel regimen]; [Antiemetics]; [Pruritus treatment]; [Sedation precautions].

24-Hour Utilization: [Total opioid consumption by route: IV scheduled/PRN, PO, PCA-delivered]; [Pain score trends]; [Sedation score trends]. (If exact totals unavailable, note estimate and limitations.)

Assessment

(Problem-oriented in descending urgency. Provide supporting facts for risk categorizations. Include differential diagnosis if pain is out of proportion or concerning for emergent conditions.)

Acute [Postoperative / Acute] Pain

[Pain mechanism: somatic / visceral / neuropathic / spasm]; [Expected vs out of proportion]; [Key contributors and functional impact]; [Regional/neuraxial status if applicable].

Opioid Tolerance/Long-term Opioid Therapy

[Opioid naïve / exposed / tolerant] — [Basis: home regimen, MME, duration]; [Respiratory depression risk factors with supporting facts]. (Include if applicable.)

OUD/MOUD Considerations

[OUD status and evidence]; [Current MOUD and coordination needs]; [Implications for perioperative analgesia]. (Include if applicable.)

Opioid-Related Adverse Effects

[Constipation, nausea, pruritus, sedation, urinary retention, delirium] — [Current status and management]. (Include if applicable.)

Regional/Neuraxial Catheter Management

[Function, spread, block density, site assessment]; [Anticoagulation timing/removal plan]; [Concerns for complications]. (Include if applicable.)

(Add other pertinent problems as needed: compartment syndrome concern, epidural hematoma risk, LAST, etc.)

Plan

Multimodal Analgesia: [Scheduled nonopioids with doses]; [Adjuvants targeted to mechanism]; [Nonpharmacologic measures]; [IV-to-PO conversion strategy and timing].

Opioid Strategy: [Drug, route, dose changes with rationale]; [Duplicate therapy avoidance]; [Taper plan]; [Bowel regimen]; [Antiemetic plan]; [Hold parameters for sedation/respiratory depression].

Regional/Neuraxial: [New intervention: candidate technique, contraindication screen, consent status] OR [Existing catheter: adjustments, removal timing]; [Surveillance plan for complications]. (If anticoagulation unknown: Defer intervention until status confirmed. Include if applicable.)

Monitoring and Safety: [Sedation and respiratory monitoring level/frequency]; [Pulse oximetry/capnography if indicated]; [Hold parameters with thresholds]; [Naloxone pathway per institutional protocol]; [Toxicity surveillance for ketamine/IV lidocaine if used].

MOUD Plan: [Continue / adjust / hold with rationale]; [Full agonist opioid plan if needed]; [Addiction medicine coordination]; [Discharge handoff to outpatient prescriber]. (Include if applicable.)

Communication: Recommendations communicated to [Name/role] at [Time] via [Method]. (If unable to reach, document attempts and interim safety actions.)

Follow-up: [Timing of next APS assessment]; [Triggers for earlier evaluation: escalating pain, new neurologic symptoms, increasing sedation, signs of toxicity].