Acute Pain Service Daily Progress Note

Date/Time: [Date and time of documentation]

Provider: [Name, credentials]

Patient Location: [Unit/Bed]

Hospital Day / POD: [Hospital day and/or postoperative day]

Procedure/Condition: [Surgery or primary pain condition]

APS Indication: [Analgesia modality and rationale]

Interval Events

[Brief 24-hour safety-relevant events summary] (If none, state: "No acute events overnight relevant to analgesia, sedation, or respiratory status." Include time-stamped details if events occurred. Confirm with nursing/primary team and note information source; do not infer absence of events.)

Subjective

[Patient-reported pain and function] (Include pain scores at rest and with activity; functional impact on recovery goals such as PT participation, cough/incentive spirometer, sleep, ambulation; what has or has not helped. Screen for side effects relevant to modality: sedation, nausea, pruritus, constipation, urinary retention, concerning numbness or weakness. State patient's analgesic goal if it influences tradeoffs. If patient unable to report, document source and reason.)

Objective

Vitals/Respiratory: [RR, SpO2, oxygen delivery method, any escalation; capnography status if monitored]

Sedation: [POSS / RASS / institutional equivalent] score [number] with observed description (Do not state "no sedation" without a score or explicit observed description.)

Exam: [General appearance/distress; pertinent positives and negatives by system; sensory level/distribution and motor strength when regional technique active]

Device/Catheter Status: (Include only if epidural, spinal, or peripheral nerve catheter is present; omit entirely if no catheter.)

• [Catheter type, location, day since placement]
• [Site condition: dressing integrity, leakage, erythema, signs of infection]
• [Current infusate and pump settings: medication, concentration, rates, bolus parameters]
• [Sensory/motor assessment relevant to block]
• [Anticoagulation status with last dose timing if relevant to removal]
• [Ambulation safety for peripheral catheters]

24h Analgesic Utilization: [What the patient actually received] (Scheduled non-opioids and adherence; opioid totals by route including PCA demands/deliveries/basal/clinician boluses; PRN doses; co-sedatives; adjuvant infusions. Note data source if incomplete.)

Pertinent Labs: [Only safety-relevant labs] (Platelets/coags for catheter decisions; creatinine for NSAIDs/gabapentinoids; LFTs if hepatotoxicity concern. Omit if none relevant.)

Assessment

[Concise clinical interpretation organized by problem or modality] (Address: adequacy of analgesia relative to function, tolerability including sedation/respiratory status and side effects, suspected mechanisms for undertreated pain, and relevant risk stratifiers such as OSA, frailty, concurrent sedatives. Label uncertainties explicitly and pair with confirmation plan.)

Plan

Analgesic Goals: [Functional targets and pain targets if used institutionally]

Regional Technique: [Continue / adjust / hold / remove] (Specify new settings if changing; anticoagulation coordination and timing for removal; planned removal date/criteria; neuro monitoring if concern exists. For peripheral catheters, address ambulation safety and removal criteria. Omit if no catheter.)

Systemic Regimen: [Scheduled non-opioids; opioid route/dose changes; PCA wean plan; adjuvants with monitoring parameters] (Highlight today's changes and rationale using start/stop/change/continue language.)

Side Effect Management: [Antiemetic, bowel regimen, pruritus treatment, urinary retention plan as relevant]

Monitoring: [Sedation score frequency; continuous oximetry/capnography if indicated; hold parameters; naloxone order status; CPAP plan if OSA]

Discharge Planning: [Transition timeline, proposed discharge analgesics, taper instructions if opioids beyond brief course, naloxone if high-risk] (Include when discharge foreseeable; omit on early hospital days.)

Communication: [Discussions with primary team, nursing, pharmacy, PT; orders placed]

(If information unavailable for any section, state explicitly why rather than leaving blank. Omit optional sections entirely if not applicable.)