Opioid Management Follow-Up Template

The opioid follow-up visit has a specific set of things that have to happen and be recorded. This template makes each one a field: benefit and harm since the last visit measured on the same instruments used at baseline, PDMP review with the date, toxicology testing considered and performed, naloxone offered and prescribed, concurrent CNS depressants with the reasoning documented, aberrant behaviour and the action taken, adverse effects, and interval events including ED visits and new prescribers.

The structure follows the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain. It asks you to reevaluate benefits and risks regularly and within one to four weeks of any dose escalation, to review the PDMP periodically during chronic therapy, to consider toxicology testing for prescribed and non-prescribed controlled substances, to use particular caution with benzodiazepines and other CNS depressants, and to treat offering naloxone as part of risk mitigation. It deliberately does not print a morphine milligram equivalent threshold, because the 2022 guideline removed fixed dosage numbers to stop them being applied as rules. It asks for the MME per day and your reasoning instead. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.