Essential Components for a Well-Structured Back Pain Note
Your back pain note must include risk stratification using the STarT Back tool at 2 weeks from pain onset, documentation of work status with consideration of a fit note, and a clear biopsychosocial assessment that drives your management plan. 1
Core Documentation Elements
Initial Assessment Components
Pain timeline and characteristics: Document exact onset date, location, radiation pattern, aggravating/relieving factors, and whether this represents acute (<6 weeks), subacute (6-12 weeks), or chronic (>12 weeks) pain 2
Red flag screening: Explicitly document absence or presence of progressive neurologic deficits, bowel/bladder dysfunction, saddle anesthesia, fever, unexplained weight loss, history of cancer, recent trauma, or immunosuppression 1
Functional impact: Record specific limitations in activities of daily living, sleep disruption, and ability to maintain usual activity levels (not just pain severity) 1, 3
Work status: Document current employment status, days missed from work, job physical demands, and whether patient is currently working or on leave 1
Risk Stratification (Critical at 2 Weeks)
Apply the STarT Back tool at 2 weeks from pain onset to categorize patients as low, medium, or high risk for developing persistent disabling pain. 1 This single assessment drives your entire management pathway and resource allocation.
- Low-risk patients: Document that self-management strategies are appropriate 1
- Medium-risk patients: Document need for physiotherapy referral with patient-centered plan 1
- High-risk patients: Document need for comprehensive biopsychosocial assessment by multidisciplinary team 1
Biopsychosocial Assessment Documentation
Psychological factors: Record fear-avoidance beliefs, catastrophizing, anxiety/depression symptoms, illness beliefs, and patient's understanding of their condition 1, 4
Social factors: Document work environment concerns, financial stressors, family support, litigation status, and barriers to care access 1, 3
Patient's explanatory model: Explicitly document what the patient believes is causing their pain and their expectations for recovery 3
Management Plan Documentation
Treatment Decisions Based on Risk Level
For all patients: Document advice to remain active (avoiding bed rest), specific pain relief prescribed (e.g., acetaminophen for minor pain 5), and self-management resources provided 1
Self-management education: List specific resources given—not just "patient education provided" but actual materials: online resources, telephone helplines, written information 1
Review timeline: Document specific follow-up plan—review within 2 weeks for initial assessment, then no later than 12 weeks for high-risk patients 1
Work-Related Documentation
Include a fit note (statement of fitness for work) that specifies how the condition affects work ability and any workplace modifications that could facilitate return to work. 1 This is not optional—work is the area of life most disrupted by back pain 1
Specialist Referral Criteria
Document consideration of specialist referral if: 1
- No improvement after 12 weeks of appropriate stratified care
- High-risk features requiring biopsychosocial assessment beyond primary care capacity
- Need for complex medication management (opioids, neuropathic pain medications)
- Consideration of high-intensity cognitive behavioral therapy
Common Documentation Pitfalls to Avoid
Don't document "physical therapy for all": This approach doesn't work—your note must show risk-stratified decision-making 1
Don't just "signpost to advice": Document specific, direct support provided with plan for frequent contact, not just handout given 1
Don't omit psychosocial factors: A purely biomedical note misses the drivers of disability and chronicity 1, 2
Don't delay risk stratification: Waiting beyond 2 weeks to apply the STarT Back tool wastes the opportunity for early intervention 1
Don't forget work documentation: Failure to address work status and provide fit notes leaves patients without crucial support for recovery 1
Patient Communication Documentation
Record that you provided: 3
- Clear explanation of diagnosis (or acknowledgment of diagnostic uncertainty)
- Legitimization of symptoms
- Shared decision-making in treatment plan
- Patient-centered, individualized approach rather than generic advice