TO CONSIDER FROM OTHER STATES. Considerations: Inform the patient of potential side effects (short- and long-term) of the prescribed medication. Inform the patient of the likelihood that tolerance and/or physical dependence on the prescribed medication will develop. The patient’s diagnosis. Inform the patient of the risk of the prescribed medication interacting with other drugs and of over-sedation. Inform the patient of the risks of impaired motor skills that affect driving among other tasks. Inform the patient of the limited evidence as to the benefit of long-term opioid therapy. Inform the patient of the risks of opioid misuse, dependence, addiction, and overdose. Inform female patients of the risks during pregnancy and after delivery. Inform the patient of alternative treatment options to opioid therapy. Inform the patient that one of the risks of opioid therapy is death. Inform the patient of the risks of withdrawal. Alcohol should not be used in combination with the prescribed opioid. All medications from other sources, including over the counters and medical marijuana, should be discussed and documented in the medical record. Note that compliance with all components of the overall treatment plan is expected. Periodic re-evaluation of treatment is needed. The patient has the option to consent to the sharing of information with family members and other providers, as necessary. Educate the patient and caregivers about the danger signs of respiratory depression and that someone should summon medical help immediately if a person demonstrates signs of respiratory depression while on opioids. Ensure the patient does not have any absolute contraindications and review risks and benefits related to any relative contraindications with the patient.
TO CONSIDER FROM OTHER STATES. Considerations: 🞎 The patient is responsible for safely using medication, meaning that the patient should store the medication in a secure location and safely dispose of any unused medication. 🞎 The goals of treatment. 🞎 The physician will be available during emergencies or otherwise have a covering physician available in the event that unforeseen problems arise and to prescribe scheduled refills. 🞎 Discuss any monitoring tools that the physician wishes to use, such as pill counts. 🞎 The patient is prohibited from sharing, giving, or selling any medication to others. 🞎 If the physician becomes concerned that there has been illegal activity, the physician may notify the authorities. 🞎 The patient provides informed, written consent for release of the agreement to local emergency departments and/or pharmacies; therefore, other providers such as ER personnel or pharmacists may report violations of the agreement back to the prescribing physician. 🞎 The prescriber’s responsibility to provide referrals to substance abuse counseling when the abuse potential is present and also for failed drug screens. 🞎 The patient may be responsible for keeping a pain diary or a diary of daily accomplishments. 🞎 If the patient violates the terms of the agreement, those violations and the physician’s response to them will be documented along with the rationale for changes in the treatment plan. INFORMED CONSENT FLORIDA
TO CONSIDER FROM OTHER STATES. Considerations: The patient is responsible for safely using medication, meaning that the patient should store the medication in a secure location and safely dispose of any unused medication. The physician will be available during emergencies or otherwise have a covering physician available in the event that unforeseen problems arise and to prescribe scheduled refills. The goals of treatment. Discuss any monitoring tools that the physician wishes to use, such as pill counts. The patient is prohibited from sharing, giving, or selling any medication to others. If the physician becomes concerned that there has been illegal activity, the physician may notify the authorities. The patient provides informed, written consent for release of the agreement to local emergency departments and/or pharmacies; therefore, other providers such as ER personnel or pharmacists may report violations of the agreement back to the prescribing physician. The prescriber’s responsibility to provide referrals to substance abuse counseling when the abuse potential is present and also for failed drug screens. The patient may be responsible for keeping a pain diary or a diary of daily accomplishments. If the patient violates the terms of the agreement, those violations and the physician’s response to them will be documented along with the rationale for changes in the treatment plan. INFORMED CONSENT OREGON STATE SPECIFIC Required by State (when prescribing for intractable pain):1 The physician shall discuss with the patient the procedures, alternatives and risks associated with prescribing controlled substances for long term management of pain. The patient will be given an opportunity to request further explanations. The patient shall sign a written document outlining the issues discussed associated with the prescribed or administered controlled substances. The material risk notice should include but not be limited to: The patient’s diagnosis. The controlled substance and/or group of controlled substances to be used.
TO CONSIDER FROM OTHER STATES. Considerations: 🞎 Discuss any monitoring tools that the physician wishes to use, such as pill counts. 🞎 The patient is prohibited from sharing, giving, or selling any medication to others. 🞎 If the physician becomes concerned that there has been illegal activity, the physician may notify the authorities. 🞎 The patient provides informed, written consent for release of the agreement to local emergency departments and/or pharmacies; therefore, other providers such as ER personnel or pharmacists may report violations of the agreement back to the prescribing physician. 🞎 The prescriber’s responsibility to provide referrals to substance abuse counseling when the abuse potential is present and also for failed drug screens. 🞎 The patient may be responsible for keeping a pain diary or a diary of daily accomplishments. 🞎 If the patient violates the terms of the agreement, those violations and the physician’s response to them will be documented along with the rationale for changes in the treatment plan. INFORMED CONSENT NEVADA
TO CONSIDER FROM OTHER STATES. Considerations: □ The physician should discuss the risks and anticipated benefits of opioid therapy with: ¤ The patient; ¤ Persons designated by the patient; or ¤ The patient’s surrogate or guardian (if patient is incompetent or without medical decision-making capacity). □ Inform the patient of potential side effects (short- and long-term) of the prescribed medication. □ Inform the patient of the likelihood that tolerance and/or physical dependence on the prescribed medication will develop. □ The patient’s diagnosis. □ Inform the patient of the risk of the prescribed medication interacting with other drugs and of over-sedation. □ Inform the patient of the risks of impaired motor skills that affect driving among other tasks. □ Inform the patient of the limited evidence as to the benefit of long-term opioid therapy. □ Inform the patient of the risks of opioid misuse, dependence, addiction, and overdose. □ Inform female patients of the risks during pregnancy and after delivery. □ Inform the patient of alternative treatment options to opioid therapy. □ Inform the patient that one of the risks of opioid therapy is death. □ Inform the patient of the risks of withdrawal. □ Alcohol should not be used in combination with the prescribed opioid. □ All medications from other sources, including over the counters and medical marijuana, should be discussed and documented in the medical record. □ Note that compliance with all components of the overall treatment plan is expected. □ Periodic re-evaluation of treatment is needed. □ The patient has the option to consent to the sharing of information with family members and other providers, as necessary. □ Educate the patient and caregivers about the danger signs of respiratory depression and that someone should summon medical help immediately if a person demonstrates signs of respiratory depression while on opioids. □ Ensure the patient does not have any absolute contraindications and review risks and benefits related to any relative contraindications with the patient.
TO CONSIDER FROM OTHER STATES. Considerations: 🞎 Inform the patient of potential side effects (short- and long-term) of the prescribed medication. 🞎 The patient’s diagnosis. 🞎 Inform the patient of the risk of the prescribed medication interacting with other drugs and of over-sedation. 🞎 Inform the patient of the risks of impaired motor skills that affect driving among other tasks. 🞎 Inform the patient of the limited evidence as to the benefit of long-term opioid therapy. 🞎 Inform the patient of the likelihood that tolerance to the prescribed medication will develop. 🞎 Inform the patient of the risks of opioid misuse, dependence, and overdose. 🞎 Inform the patient that one of the risks of opioid therapy is death. 🞎 Inform the patient of the risks of withdrawal. 🞎 Alcohol should not be used in combination with the prescribed opioid. 🞎 All medications from other sources, including over the counters and medical marijuana, should be discussed and documented in the medical record. �� Note that compliance with all components of the overall treatment plan is expected. 🞎 Periodic re-evaluation of treatment is needed. 🞎 The patient has the option to consent to the sharing of information with family members and other providers, as necessary. 🞎 Educate the patient and caregivers about the danger signs of respiratory depression and that someone should summon medical help immediately if a person demonstrates signs of respiratory depression while on opioids. 🞎 Ensure the patient does not have any absolute contraindications and review risks and benefits related to any relative contraindications with the patient.
TO CONSIDER FROM OTHER STATES. Considerations: 🞎 The patient’s diagnosis. 🞎 Inform female patients of the risks during pregnancy and after delivery. 🞎 Inform the patient of alternative treatment options to opioid therapy. 🞎 Inform the patient that one of the risks of opioid therapy is death. 🞎 Inform the patient of the risks of withdrawal. 🞎 Alcohol should not be used in combination with the prescribed opioid. 🞎 All medications from other sources, including over the counters and medical marijuana, should be discussed and documented in the medical record. 🞎 Note that compliance with all components of the overall treatment plan is expected. 🞎 Periodic re-evaluation of treatment is needed. 🞎 The patient has the option to consent to the sharing of information with family members and other providers, as necessary. 🞎 Educate the patient and caregivers about the danger signs of respiratory depression and that someone should summon medical help immediately if a person demonstrates signs of respiratory depression while on opioids. 🞎 Ensure the patient does not have any absolute contraindications and review risks and benefits related to any relative contraindications with the patient.
TO CONSIDER FROM OTHER STATES. Considerations: Discuss any monitoring tools that the physician wishes to use, such as pill counts. The patient is prohibited from sharing, giving, or selling any medication to others. If the physician becomes concerned that there has been illegal activity, the physician may notify the authorities. The patient provides informed, written consent for release of the agreement to local emergency departments and/or pharmacies; therefore, other providers such as ER personnel or pharmacists may report violations of the agreement back to the prescribing physician. The patient may be responsible for keeping a pain diary or a diary of daily accomplishments. If the patient violates the terms of the agreement, those violations and the physician’s response to them will be documented along with the rationale for changes in the treatment plan. INFORMED CONSENT SOUTH CAROLINA STATE SPECIFIC Required by State: No requirements.
TO CONSIDER FROM OTHER STATES. Considerations: The goals of treatment. The physician will be available during emergencies or otherwise have a covering physician available in the event that unforeseen problems arise and to prescribe scheduled refills. The patient is prohibited from sharing, giving, or selling any medication to others. The prescriber’s responsibility to provide referrals to substance abuse counseling when the abuse potential is present and also for failed drug screens. The patient may be responsible for keeping a pain diary or a diary of daily accomplishments. INFORMED CONSENT MAINE STATE SPECIFIC
TO CONSIDER FROM OTHER STATES. Considerations: Inform the patient of potential side effects (short- and long-term) of the prescribed medication. The patient’s diagnosis. Inform the patient of the risk of the prescribed medication interacting with other drugs and of over-sedation. Inform the patient of the risks of impaired motor skills that affect driving among other tasks. Inform the patient of the limited evidence as to the benefit of long-term opioid therapy. Inform the patient of the likelihood that tolerance to the prescribed medication will develop. Inform female patients of the risks during pregnancy and after delivery. Inform the patient of alternative treatment options to opioid therapy. Inform the patient that one of the risks of opioid therapy is death. Inform the patient of the risks of opioid misuse and overdose. Inform the patient of the risks of withdrawal. Alcohol should not be used in combination with the prescribed opioid. All medications from other sources, including over the counters and medical marijuana, should be discussed and documented in the medical record. Note that compliance with all components of the overall treatment plan is expected. Periodic re-evaluation of treatment is needed. The patient has the option to consent to the sharing of information with family members and other providers, as necessary. Educate the patient and caregivers about the danger signs of respiratory depression and that someone should summon medical help immediately if a person demonstrates signs of respiratory depression while on opioids. Ensure the patient does not have any absolute contraindications and review risks and benefits related to any relative contraindications with the patient.
