Inpatient Pain Consultation Note

Date/Time of Service: [Date and time of encounter]

Author/Role: [Clinician name and role/title]

Patient Location: [Unit and room/bed]

Primary Service/Attending: [Primary inpatient service and attending name]

Consulting Service: [Consulting service name]

Consult Request Date/Time: [Date and time consult was requested]

Requesting Clinician/Service: [Name and service of requesting clinician] (If not identifiable in chart, state "not identifiable in chart.")

Consult Priority: [routine / urgent / emergent]

History Sources and Limitations: [Sources: patient / family / chart / pharmacy / clinician report] (Note any limitations such as delirium, intubation, language barrier, altered mental status.)

Reason for Consult

[One problem-focused sentence stating the clinical reason for pain consultation, followed by the specific clinical question(s) being asked] (Questions should be concrete and actionable, e.g., optimize multimodal regimen given opioid tolerance and renal dysfunction; evaluate candidacy for regional analgesia; develop discharge pain plan with taper.)

Summary

[Concise 3–6 line summary including: working pain diagnosis/mechanism, opioid tolerance status with basis, key safety risks, top 2–4 actionable recommendations, and discharge trajectory implications] (Include for most consults, especially complex cases.)

History of Present Illness

[Narrative of onset/precipitating event, pain location and radiation, quality, severity with functional impact, aggravating/alleviating factors, response to current regimen, and any red flag symptoms. Include current functional goals.] (Document functional impact such as sleep, mobility, pulmonary toilet, PT tolerance—not just numeric pain scores. Note red flags: new neurologic deficits, bowel/bladder changes, escalating somnolence.)

Chronic Pain and Baseline Regimen

(Include when acute-on-chronic pain or possible opioid tolerance.)

• [Chronic pain diagnoses and typical baseline pain/function]
• [Home analgesic regimen with prescriber(s) identified and source of verification]
• [Prior effective/ineffective treatments and adverse reactions]
• [Prior procedures/interventions and non-pharmacologic therapies with outcomes]
• [Prior opioid complications] (Only include if applicable: overdose, severe constipation, delirium, withdrawal.)

Current Analgesic Exposure

• Home regimen verification: [verified via pharmacy/PDMP/med rec / patient-reported only]
• Pre-hospital analgesics: [Agents, doses, frequencies, routes, last intake times]
• Inpatient analgesics (last 24 hours):
  • [Scheduled opioids: agent, dose, route, timing]
  • [PRN opioids given: agent, dose, route, timing]
  • [Non-opioid adjuncts with dosing]
  • [Continuous infusions if any: agent, dose/rate, start time]
  • [Regional techniques: drug, concentration, rate/settings]
• Total OME (last 24 hours): [Calculated OME in mg with method] (If not reliably calculable, state why and note conservative plan will be used until verified.)
• Opioid tolerance determination: [opioid-naïve / opioid-tolerant / unclear—basis] (Base explicitly on documented dosing history and verification status. Do not assume tolerance if unverifiable.)

Safety and Risk Factors

(Include whenever opioids are being used or considered.)

• Respiratory risk: [OSA/CPAP use, COPD, baseline O2 requirement, obesity, age/frailty]
• Concurrent CNS depressants: [Benzodiazepines, Z-drugs, gabapentinoids, alcohol, others]
• Renal/hepatic impairment: [CKD stage, hepatic dysfunction, implications for drug clearance]
• Delirium/fall risk: [present / absent, contributing factors]
• In-admission events: [Prior naloxone, oversedation episodes, rapid response related to sedation]
• GI function: [Constipation/ileus risk, last BM, bowel regimen in place]
• Substance use history: [Tobacco, alcohol, illicit substances, non-prescribed opioid use, OUD history, MAT status] (If negative or unknown, note briefly.)

Pertinent Medical/Surgical History

(Focus on items affecting analgesic selection or procedural candidacy.)

• [Anticoagulation/antiplatelet therapy with last dose time and indication]
• [Cardiac disease and hemodynamic considerations]
• [Seizure history]
• [Psychiatric history relevant to analgesic selection]
• [GI ulcer/bleed history]
• [Liver disease]
• [CKD/renal dosing considerations]
• [Relevant surgeries or procedural sites]

Allergies

• [Allergen: reaction type] (Differentiate true allergy vs intolerance vs inefficacy.)

Review of Systems

(Include only if findings change the differential or safety assessment; omit section entirely if not contributory.)

• [Neurologic: new weakness, numbness, saddle anesthesia]
• [Constitutional/infectious: fever, chills]
• [GI/GU: bowel/bladder dysfunction]
• [Other system findings relevant to pain/safety]

Objective

Vitals and Monitoring Context

• [Recent vitals with trends: BP, HR, RR, Temp, SpO2]
• [Oxygenation status: room air / supplemental O2—device and flow/FiO2]
• [Monitoring status: continuous pulse oximetry / capnography / standard floor monitoring]
• [Sedation level: RASS or POSS score with arousability assessment]

Physical Exam

• General: [Distress/comfort, posture, interaction]
• Mental status: [Alertness, orientation, delirium features]
• Respiratory: [Effort, speech in full sentences, accessory muscle use]
• Pain-focused exam: [Surgical site/abdomen/spine/joints: inspection, palpation, tenderness, guarding]
• Neurologic: [Motor strength, sensation, reflexes, allodynia/hyperalgesia] (Include when indicated.)
• Regional catheter: [Site condition, dressing integrity, sensory/motor findings, pump settings, signs of local anesthetic toxicity] (Include if catheter present.)

Pertinent Labs/Imaging

• [Renal function, hepatic panel]
• [Platelets/INR] (If procedure considered.)
• [ABG/VBG] (If hypercapnia/sedation concern.)
• [Imaging relevant to pain generator or procedural planning]

Medication Administration Review

• [Analgesics actually administered with times in last 24 hours]
• [PCA details: drug concentration, demand dose, lockout, basal rate, totals, adverse events or pump alarms] (Include if PCA in use.)

Assessment

(Use problem-based format in descending order of acuity/safety importance.)

[Problem 1: Diagnosis and pain mechanism]

[Assessment with supporting findings, differential if relevant, safety framing including opioid tolerance status and respiratory depression risk, and barriers to safe discharge if applicable] (Address opioid-induced hyperalgesia vs withdrawal vs uncontrolled pain when relevant.)

[Problem 2: Diagnosis]

[Assessment] (Include additional problems as needed.)

Plan

Overall Analgesia Goals: [Functional goals rather than numeric targets; multimodal strategy; monitoring and reassessment plan]

[Problem 1: Plan]

• Non-pharmacologic: [Positioning, heat/ice, splinting, mobilization timing, relaxation techniques]
• Non-opioid pharmacologic: [Acetaminophen schedule/max dose; NSAIDs with contraindications; neuropathic agents with renal dosing; muscle relaxants; topicals]
• Opioid strategy: [Tolerance category with basis; route rationale; scheduled vs PRN approach; conversion/rotation with equianalgesic rationale; hold parameters tied to sedation/respiratory status; rescue plan] (Include if opioids indicated.)
• Regional/interventional: [Candidate procedure and target; expected benefit; contraindications checklist including anticoagulant timing compliance; consent summary; logistics and post-procedure monitoring] (Include if procedure considered.)
• Advanced infusions: [Indication; contraindications screened; monitoring requirements; service ownership; stop criteria] (Include if ketamine/lidocaine/dexmedetomidine used.)
• Safety orders: [Bowel regimen; antiemetic PRN; pruritus management if neuraxial opioids; delirium precautions; naloxone availability with criteria; respiratory monitoring recommendations]
• Coordination: [Requests to primary team; pharmacy involvement; PT/OT timing; addiction medicine consultation if indicated]

(Safety cautions when relevant: avoid basal PCA in opioid-naïve patients without enhanced monitoring; avoid multiple concurrent short-acting opioids; avoid initiating long-acting opioids for acute pain without confirmed outpatient continuity.)

[Problem 2: Plan]

[Follow same structure as Problem 1] (Include additional problems as needed.)

Discharge Pain Plan

• Anticipated discharge and prerequisites: [Timeframe and pain-related readiness criteria]
• Proposed discharge regimen: [Non-opioids to continue; opioid plan with taper if needed; bowel regimen]
• Naloxone: [Indication and provision plan] (Include if opioids will be prescribed.)
• Outpatient prescriber: [Pain clinic / PCP / surgeon—continuity status] (If not confirmed, document explicitly and recommend conservative bridge with urgent follow-up.)
• Patient/family education: [Safe use, storage, disposal, warning signs—completed or planned]
• Follow-up: [Appointments, referrals, timeline, responsibilities]

Recommendations Communicated

• Contact: [Name, role, date/time of communication]
• Recommendations: [Key recommendations relayed and whether accepted]
• Time-sensitive elements: [Anticoagulant holds with exact timing; escalation steps if not implemented]