Progress Note

Pain Assessment and Documentation Tool (PADT™)

Patient Stamp Here

Patient Name: ________________________________ Record #:_____________________

Assessment Date: ___________________________________________________________

Current Analgesic Regimen

Drug Name Strength (eg, mg) Frequency Maximum Total Daily Dose

The PADT is a clinician-directed interview; that is, the clinician asks the questions, and the clinician records the responses. The Analgesia,
Activities of Daily Living, and Adverse Events sections may be completed by the physician, nurse practitioner, physician assistant, or nurse. The
Potential Aberrant Drug-Related Behavior and Assessment sections must be completed by the physician. Ask the patient the questions below,
except as noted.

Analgesia Activities of Daily Living

If zero indicates “no pain” and ten indicates “pain as bad Please indicate whether the patient’s functioning with the
as it can be,” on a scale of 0 to 10, what is your level of current pain reliever(s) is Better, the Same, or Worse since
pain for the following questions? the patient’s last assessment with the PADT.* (Please
check the box for Better, Same, or Worse for each item
1. What was your pain level on average during the past below.)
week? (Please circle the appropriate number)
Better Same Worse
No Pain 0 1 2 3 4 5 6 7 8 9 10 Pain as bad
as it can be
1. Physical functioning
2. What was your pain level at its worst during the past
week?
2. Family relationships
No Pain 0 1 2 3 4 5 6 7 8 9 10 Pain as bad
as it can be
3. Social relationships
3. What percentage of your pain has been relieved
during the past week? (Write in a percentage
between 0% and 100%.) 4. Mood
__________________________________________

4. Is the amount of pain relief you are now obtaining

5. Sleep patterns
from your current pain reliever(s) enough to make a
real difference in your life?
6. Overall functioning
Yes No
*If the patient is receiving his or her first PADT
5. Query to clinician: Is the patient’s pain relief assessment, the clinician should compare the patient’s
clinically significant? functional status with other reports from the last office
visit.
Yes No Unsure

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(Continued on reverse side)

 Progress Note
Pain Assessment and Documentation Tool (PADT™)
Adverse Events Potential Aberrant Drug-Related Behavior
This section must be completed by the physician
Please check any of the following items that you
1. Is patient experiencing any side effects from current discovered during your interactions with the patient.
pain reliever? Yes No Please note that some of these are directly observable
(eg, appears intoxicated), while others may require more
active listening and/or probing. Use the “Assessment”
section below to note additional details.
Ask patient about potential side effects:
None Mild Moderate Severe Purposeful over-sedation
a. Nausea Negative mood change
Appears intoxicated
b. Vomiting Increasingly unkempt or impaired
Involvement in car or other accident
c. Constipation Requests frequent early renewals
Increased dose without authorization
d. Itching Reports lost or stolen prescriptions
Attempts to obtain prescriptions from other
doctors
e. Mental cloudiness Changes route of administration
Uses pain medication in response to
situational stressor
f. Sweating Insists on certain medications by name
Contact with street drug culture
g. Fatigue Abusing alcohol or illicit drugs
Hoarding (ie, stockpiling) of medication
h. Drowsiness Arrested by police
Victim of abuse
i. Other___________________ Other: _________________________________
____________________________________________
j. Other___________________ ____________________________________________
2. Patients overall severity of side effects?
None Mild Moderate Severe
Assessment: (This section must be completed by the physician.)
Is your overall impression that this patient is benefiting (eg, benefits, such as pain relief, outweigh side effects) from
opioid therapy? Yes No Unsure
Comments: _______________________________________________________________________________________
_________________________________________________________________________________________________
Specific Analgesic Plan: Comments:_____________________________________________
Continue present regimen ______________________________________________________
Adjust dose of present analgesic ______________________________________________________
Switch analgesics ______________________________________________________
Add/Adjust concomitant therapy ______________________________________________________
Discontinue/taper off opioid therapy
Date:______________________________ Physicians Signature: ___________________________________________
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