What is the recommended approach for documenting lower back pain assessment?

Documentation of Lower Back Pain Assessment

Clinicians should document a focused history and physical examination that categorizes patients with low back pain into one of three categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. 1

Essential Documentation Components

History Documentation

• Pain characteristics:

  • Location and radiation pattern
  • Frequency and duration of symptoms
  • Onset (gradual vs sudden)
  • Aggravating and alleviating factors
  • Previous episodes and treatments with responses

• Red flags (document presence or absence):

  • History of cancer
  • Unexplained weight loss
  • Immunosuppression
  • Prolonged steroid use
  • IV drug use
  • Recent infection
  • Age >50 years
  • Trauma
  • Saddle anesthesia
  • Urinary retention or incontinence
  • Fecal incontinence
  • Progressive neurological deficits

• Yellow flags (psychosocial risk factors):

  • Negative attitudes/beliefs about pain
  • Fear-avoidance behaviors
  • Catastrophizing
  • Depression or anxiety
  • Work-related issues
  • Social support problems

Physical Examination Documentation

• Gait and posture assessment
• Range of motion measurements
• Neurological examination:
  • Motor strength (document specific muscle groups tested)
  • Sensory testing (document specific dermatomes)
  • Deep tendon reflexes
  • Straight leg raise test results
• Palpation findings
• Special tests performed and results

Documentation Framework by Category

1. Nonspecific Low Back Pain (>85% of cases) 1

• Document normal neurological examination
• Document absence of red flags
• Document functional limitations
• Document pain severity using validated scale (e.g., 0-10 numeric rating)

2. Back Pain with Radiculopathy or Spinal Stenosis

• Document specific neurological findings
• Document specific dermatomal patterns
• Document results of provocative tests (e.g., straight leg raise)
• Document functional limitations related to neurological symptoms

3. Back Pain with Specific Spinal Cause

• Document specific red flags identified
• Document examination findings supporting specific diagnosis
• Document rationale for diagnostic testing ordered

Imaging Documentation

• Document justification if imaging is ordered, based on:
  • Severe/progressive neurological deficits
  • Suspected serious underlying condition
  • Persistent symptoms with radiculopathy/stenosis in surgical candidates 1, 2
• Document why routine imaging was not performed for nonspecific low back pain 1

Treatment Plan Documentation

• Document patient education provided
• Document self-care instructions given
• Document activity recommendations
• Document medication plan with rationale
• Document follow-up timeline and criteria for reassessment

Risk Stratification Documentation

• Consider documenting STarT Back tool results to categorize patients into risk levels 2:
  • Low risk: Self-management approach
  • Medium risk: Physiotherapy referral
  • High risk: Comprehensive biopsychosocial assessment

Common Documentation Pitfalls to Avoid

• Failing to document assessment of red flags
• Omitting psychosocial assessment
• Ordering imaging without documenting clear indications
• Inadequate documentation of neurological examination
• Failing to document functional impact of pain
• Not documenting previous treatments and responses

By following this structured documentation approach, clinicians can ensure comprehensive assessment of low back pain that guides appropriate management decisions and supports continuity of care.