Recommended Approach for Documenting Low Back Pain Assessment
Documentation of low back pain assessment should follow a structured approach that categorizes patients into one of three broad 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
1. History Documentation
Pain characteristics:
- Onset (sudden vs. gradual)
- Duration (acute < 4 weeks, subacute 4-12 weeks, chronic > 12 weeks)
- Location and radiation pattern
- Quality (sharp, dull, burning, etc.)
- Severity (0-10 scale)
- Aggravating and alleviating factors
- Previous episodes and treatments
Red flags (document presence or absence):
Yellow flags (psychosocial risk factors):
2. Physical Examination Documentation
General observation:
- Gait pattern
- Posture
- Pain behaviors
Spine examination:
- Inspection for deformity, asymmetry
- Palpation for tenderness, muscle spasm
- Range of motion (flexion, extension, lateral bending, rotation)
- Pain with movement
Neurological assessment:
3. Functional Assessment Documentation
- Impact on activities of daily living
- Work limitations
- Sleep disturbances
- Functional goals 3
Documentation of Diagnostic Category
Based on the history and physical examination, document which of the three categories the patient falls into:
Nonspecific low back pain: Most common (85% of cases); no specific pathoanatomical cause identified
Back pain potentially associated with radiculopathy or spinal stenosis:
- Document specific neurological findings
- Note dermatomal distribution of symptoms
- Document positive provocative tests
Back pain potentially associated with another specific spinal cause:
- Document specific suspected diagnosis
- Note red flags that led to this suspicion 1
Imaging and Diagnostic Testing Documentation
Document rationale for ordering or not ordering imaging studies:
When documenting imaging orders, specify:
- Type of imaging (MRI preferred for neurological symptoms)
- Clinical question to be answered
- Red flags or specific indications 3
Treatment Plan Documentation
Document evidence-based information provided to patient about:
- Expected course of low back pain
- Importance of remaining active
- Self-care options 1
Medication plan (if prescribed):
Non-pharmacologic therapies (as appropriate):
- For acute pain: Spinal manipulation
- For chronic/subacute pain: Document recommendation for:
- Exercise therapy
- Intensive interdisciplinary rehabilitation
- Acupuncture
- Massage therapy
- Spinal manipulation
- Yoga
- Cognitive-behavioral therapy
- Progressive relaxation 1
Follow-up Plan Documentation
- Document specific timeframe for follow-up
- Criteria for earlier reassessment
- Specific goals to assess at follow-up
- Plan if symptoms persist beyond 6 weeks 3
Risk Stratification Documentation
- Consider documenting STarT Back tool results to categorize patients into:
- Low risk: Self-management plan
- Medium risk: Physiotherapy referral with patient-centered plan
- High risk: Comprehensive biopsychosocial assessment 3
Common Documentation Pitfalls to Avoid
- Failing to document assessment of red flags
- Incomplete neurological examination documentation
- Ordering imaging without documenting specific indications
- Vague treatment plans without specific goals
- Missing documentation of psychosocial factors that may influence recovery 1, 3
By following this structured documentation approach, clinicians can ensure comprehensive assessment of low back pain that guides appropriate management and improves patient outcomes.