Pain Management Clinical Operational Manual

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SKU: PM-Vol1-2-3 Category:

Pain Management Clinical Operations Manual

TABLE OF CONTENTS
SECTION I: STATE OF FLORIDA PAIN MANAGEMENT LEGISLATION

A. FLORIDA PAIN LEGISLATION AND CHECKLIST
A1 Checklist for FL Pain Management Treatment Involving Opioid Therapy….. 000003 A2 2011 State of Florida Pain Management Legislation 00003.1
SECTION II: CLINICAL OPERATIONS
B. CLINICAL PROTOCOLS
B1 Confidentiality of Patient Information 000005
B2 Clinical Record Contents 000007
B3 P&P- Documentation Protocol 000008
B4 P&P-Abbreviations 000010
B5 Approved Abbreviations, Acronyms and Symbols 000011
B6 Injuries/Medical Problems/Medical Emergencies 000020
PRESCRIPTIONS
B7 Written & Electronic Prescriptions for Medicinal Drugs 000023
B8 Written & Electronic Prescriptions for Controlled Substances 000024
B9 Controlled Substance Prescribing 000025
OFFICE SURGERY
B10 Informed Consent for Procedures 000027
B11 P&P – Standard of Care for Office Surgery 000028
B12 Patient Instructions for Procedures 000033
Discharge Instructions for :
B13 Cervical and Thoracic Epidural Steroid Injections 000034
B14 Epidural Steroid Injection & Lumbar Sympathetic Block……. 000035 B15 Stellate Ganglion, Interscalene & Axillary Blocks 000036
C. ASSESSMENTS
C1 P&P – Patient Assessment and Patient Care Process 000037
C2 P&P – Pain Assessment 000039
C3 P&P – Medical Assessment 000040
C4 P&P – Behavioral Management 000041
C5 Chronic Pain & Chemical Dependency Assessment and Contracts 000043
C6 Patient Pain Questionnaire 000046
C7 Substance Abuse and Psychosocial Assessment- Form 000048
C8 P&P- Substance Abuse Referrals 000049

Pain Management Clinical Operations Manual
C9 Neurological Orthopedic Assessment 000050
D. INITIAL EVALUATION AND MEDICAL HISTORY
New Patient Evaluation & Management Services
D1 Part I – Assessment & Medical History 000051
D2 Part II – Physical Exam 000055
D3 Initial Evaluation for Pain Management Services including
Substance Abuse and Psychosocial Assessment 000056
D4 Initial Evaluation & Management Services 000062
D5 P&P – Use of Controlled Substances for Treatment 000068
D6 Contract for Use of Controlled Substances for Treatment 000069
D7 Aberrant Drug-Related Behaviors 000071
E . TREATMENT PLANNING
E1 P&P – Multidisciplinary Collaboration 000072
E2 P&P – Initial Treatment Plan 000073
E3 P&P – Master Treatment Plan 000074
E4 Master Treatment Plan – Form 000075
E5 P&P – Treatment Plan Update 000077
E6 Treatment Plan Update – Form 000078
E7 Certificate of Medical Necessity 000079
F. COLLABORATION AND REFERRAL
F Referral to External Healthcare Provider 000080
F Collaboration with Caregivers 000081
F Community Agencies and Resources 000082
G. DOCUMENTATION
G1 Evaluation & Management Services for the Established Patient 000083
G2 Dictation Outline for E&M Services for an Established Patient 000085
G3 Patient Medication Profile 000087
G4 P&P – Medication Administration 000088
G5 P&P – Medications – Vials 000089
G6 P&P – Sample Medications 000090
G7 Sample Medications Patient Distribution Log 000091
G8 Sample Medications Donation Log 000092
G9 P&P – Assessing Vital Signs 000093
G10 Vital Signs and Weight Record 000094

Pain Management Clinical Operations Manual
G11 Problem List 000095
H. LABORATORY SERVICES
H1 P&P – Waived Testing 000096
H2 Drug Testing Protocol 000097
H3 Venipunctures 000098
H4 Lab Specimens Log 000100
H5 P&P – Daily Logs and Monitoring 000101
H6 P&P – Refrigerator/Freezer Temperature Log 000102

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