Back Pain HPI Template for Emergency Room Documentation
A comprehensive back pain HPI template for ER documentation should include pain characteristics, red flags, neurological assessment, and risk factors for serious pathology 1. This structured approach ensures proper evaluation and documentation while prioritizing identification of potentially serious conditions requiring urgent intervention.
Essential Elements of Back Pain HPI Template
Pain Characteristics
- Location and Radiation: Precise anatomical location (thoracic, lumbar, sacral) and radiation patterns (e.g., radicular symptoms to lower extremities)
- Onset and Duration: Sudden vs. gradual onset; acute (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks) 2
- Quality: Description of pain (sharp, dull, burning, electric)
- Severity: Pain scale rating (0-10)
- Timing: Constant vs. intermittent; diurnal variations
- Aggravating/Alleviating Factors: Activities or positions that worsen or improve symptoms
- Prior Episodes: History of similar pain, treatments tried, and effectiveness
Red Flag Assessment
- Fever/Chills: Potential indicator of infection
- Night Pain: May suggest tumor, infection, or inflammatory conditions
- Constant Pain Unrelieved by Position Change: Concerning for serious pathology
- Bowel/Bladder Dysfunction: Urgently assess for cauda equina syndrome
- Saddle Anesthesia: Perineal numbness suggesting cauda equina syndrome
- Progressive Neurological Deficits: Worsening weakness or sensory changes
- Weight Loss/Constitutional Symptoms: May indicate malignancy
- Recent Trauma: History of falls or accidents, especially in elderly or osteoporotic patients
- Age >65 or <18: Higher risk for serious pathology 1
Neurological Assessment
- Motor Function: Strength in major muscle groups (grade 0-5)
- Sensory Changes: Distribution of numbness or paresthesias
- Reflexes: Deep tendon reflexes and pathological reflexes
- Straight Leg Raise: Positive/negative and at what degree
- Gait Assessment: Normal vs. abnormal
Risk Factors for Serious Pathology
- Age >65: Higher risk for fractures, malignancy
- History of Cancer: Type, treatments, remission status
- Immunosuppression: HIV, chronic steroids, transplant medications
- IV Drug Use: Risk for spinal infections
- Osteoporosis: Diagnosed or risk factors
- Prolonged Steroid Use: Duration and dosage 2
Inflammatory Back Pain Features
- Age of Onset <40 Years
- Insidious Onset
- Improvement with Exercise
- No Improvement with Rest
- Pain at Night (Improving Upon Getting Up)
- Morning Stiffness >30 Minutes 2
Mechanical Factors
- Occupation: Physically demanding work
- Sports/Activities: High-impact or repetitive activities
- For Women: Pregnancy history, number of children, date of most recent delivery 2
Prior Treatments and Response
- Medications: NSAIDs, muscle relaxants, opioids, etc.
- Physical Therapy: Type and duration
- Injections: Type, location, and effectiveness
- Prior Imaging: Results of previous studies
- Prior Surgeries: Type and date of spinal procedures
Documentation Algorithm
- Initial Assessment: Document pain characteristics and red flags first
- If Red Flags Present: Document detailed neurological examination and order appropriate imaging immediately 1
- If No Red Flags: Document mechanical factors, prior treatments, and response
- For Chronic Pain: Include psychosocial factors (depression, anxiety, catastrophizing)
- For Suspected Inflammatory Back Pain: Document inflammatory features and consider HLA-B27 testing 2
Common Pitfalls to Avoid
- Inadequate Red Flag Assessment: Missing serious pathology requiring urgent intervention
- Incomplete Neurological Examination: Failing to document key neurological findings
- Overreliance on Imaging: Remember that routine imaging is not recommended for uncomplicated back pain within the first 4-6 weeks 1
- Failure to Document Prior Treatments: Important for determining next steps in management
- Incomplete Documentation of Pain Characteristics: Essential for differential diagnosis and treatment planning
By following this comprehensive template, emergency physicians can ensure thorough documentation of back pain presentations, facilitate appropriate management decisions, and avoid missing serious pathology requiring urgent intervention.