Opioid Chart Review Checklist

Instructions: First, choose a chart of a patient that meets the following criteria: 1) the patient has a chronic non-cancer pain diagnosis (i.e.
pain duration longer than 6 months), 2) current daily opioid therapy, 3) trial of opioid therapy began in the past 6 months, 4) opioids
prescribed continuously for more than 3 months (chronic opioid therapy – COT). Second, gather all sources of information, assign at least
30 minutes to each chart, and refer to Opioid Manager ©.

Notes: 1) Do not include charts for patients whose opioid prescription is primarily managed by another provider; 2) Charts of patients
who were inherited from another provider may be included.

Suggested Sources of Info: Rx copies, chart notes, admission history and physical, addiction assessment, protocols, policies, UDS results,
correspondence, attendance schedules, incident reports, reports of other Rx, treatment plan, patient profile, etc.

Date of Review: ________________________

Prescriber ID: ______________________
Chart Review ID Number: _________________________
Patient year of birth: __________________
Diagnosis(-es) of chronic non-cancer pain condition: _____________________________________________________
Approximate date of initiating daily opioid therapy: ____________________________________________________________
Type(s) of opioid currently being prescribed, dose and frequency [most recent prescription]:
Opioid Dose Frequency Quantity

Meets Partially Does not N/A Notes Suggestions

meets meet
Initial Patient Assessment (or included in Cumulative Patient Profile)
- first documented discussion of opioid trial

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 Meets Partially Does not N/A Notes Suggestions
meets meet
1. The physician documents a clear
initial assessment of the pain
condition: cause, type duration
and pattern and intensity
2. The physician clearly documents
indications for opioid prescribing
3. The physician documents a clear
assessment of general medical
condition
4. The physician documents a clear
assessment of psychiatric status
5. The physician documents a clear
assessment of substance use
history
6. The physician documents a clear
assessment of psychosocial
history
7. The physician documents a clear
assessment of contraindications
and relative contraindications to
opioid prescribing (including
pregnancy)
8. The physician documents a clear Used Not
assessment of opioid risk using Used
the Opioid Risk Tool or
equivalent [Optional]
9. The physician documents a clear
assessment of all prescribed
medications
10. The physician documents a clear
assessment of all non-
pharmacologic pain treatment
11. The physician documents a clear
assessment of co-existing use of
alcohol or illicit substances
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 Meets Partially Does not N/A Notes Suggestions
meets meet
12. The physician has a written Used Not
treatment agreement signed by Used
the patient and documented in
the chart prior to initiating
opioids [Optional]
13. The physician has documented Used Not
baseline urine monitoring and Used
appropriate interpretation on
first presentation [Optional]
Treatment Initiation
- first prescription of opioid trial
1. The physician documents a clear
treatment initiation plan -
starting dose, formulation
(liquid/tablet etc), duration
before dose adjustment;
2. The physician has given advice
on use of PRN doses
3. Patients began management with
lower strength opioid type
[Stepped Approach]
4. The physician has prescribed an
appropriate starting dose
Table B-9.1
5. The physician documents
discussion about treatment goals
6. The physician documents other
pharmacotherapies, psychosocial
treatments, physical therapies,
and complementary and
alternative medicine treatments
Patient Education
1. The physician has given patient
appropriate warning(s)/ advice
on side effects and serious

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 Meets Partially Does not N/A Notes Suggestions
meets meet
adverse effects (including
addiction/abuse/misuse)
2. The patient is able to safely store
and administer the medication,
the risks of diverted opioids, and
that s/he agrees never to give or
sell his/her opioids
3. The physician has counseled the
patient on issues related to
pregnancy (for females of
childbearing age)
4. The physician advises the patient
to avoid driving a motor vehicle
until a stable dosage is
established and it is certain the
opioid does not cause sedation
5. The physician has counseled the
patient on strategies to avoid
opioid overdose
Monitoring
1. The physician reviews the
patient at appropriate intervals
[No longer than 4 weeks after
initiation or adjustment; no
longer than 3 months on stable
dose]
2. The physician has documented
review of pain severity
measurement
3. The physician has documented
review of functioning
4. The physician has documented
review of side effects and serious
adverse effects

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 Meets Partially Does not N/A Notes Suggestions
meets meet
5. The physician has documented
review of other
pharmacotherapies, psychosocial
treatments, physical therapies,
and complementary and
alternative medicine treatments
6. The physician has documented
progress toward/revision of
treatment goals
8. The physician has documented
review for signs of opioid use
disorder/aberrant drug-related
behaviors
9. The physician has clearly
documented the pain
management plan
10. The physician has clearly
documented dose adjustment
regime and pain monitoring that
informs dose adjustment (a) intended dose adjustment regime documented (b) records documen
11. The dose adjustment does not
exceed the suggested dose
increase (refer to Opioid
Manager ©)
12. The dose adjustment does not
occur before minimum time
interval for increase (refer to
Opioid Manager ©)
13. The physician has given advice
on use of PRN doses
14. If the physician exceeds the
watchful opioid dose of 200
mg/day of morphine or
equivalent, there is
documentation of careful re-

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 Meets Partially Does not N/A Notes Suggestions
meets meet
assessments and frequent
monitoring for improved patient
outcomes

** The Opioid Chart Review Checklist was developed using CPSO’s methadone practice assessment checklist as a template and modified for use in chart reviews for
opioid prescribing for the purpose of this study. CPSO is not responsible in any way for this product or the use or results from the use of this product.

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