Can you provide a comprehensive pain management clinic visit note template that includes patient identifier, chief complaint, history of present pain, past medical history, surgical history, medications (including analgesics, adjuvant agents, opioid regimen), allergies, review of systems, physical examination, pain assessment, assessment/problem list, and plan (pharmacologic, non‑pharmacologic, interventional, monitoring, education, referrals)?

Pain Management Clinic Visit Note Template

A comprehensive pain management clinic visit note should systematically document patient demographics, pain characteristics, treatment history, physical findings, and a detailed management plan with specific pharmacologic, non-pharmacologic, and interventional strategies, along with mandatory patient education and safety monitoring protocols. 1

Patient Identification Section

• Demographics: Name, date of birth, medical record number, date of visit 2
• Insurance/Authorization: Document prior authorizations for controlled substances and interventional procedures 2
• Referring Provider: Include contact information for coordination of care 1

Chief Complaint and Pain History

• Primary Pain Location(s): Use body diagram or specify anatomical regions with percentage of body surface area affected when applicable 3

• Pain Characteristics:

  • Onset, duration, frequency (constant vs. intermittent) 2
  • Quality (sharp, burning, aching, shooting) 2
  • Numerical pain intensity (0-10 scale): current, average, worst, and least pain in past 24 hours 4, 2
  • Aggravating and alleviating factors 2
  • Impact on function and activities of daily living 2

• Previous Pain Treatments: Document all prior therapies including medications, interventional procedures, physical therapy, psychological interventions, and their effectiveness 5, 2

Past Medical and Surgical History

• Comorbidities: Specifically document cardiovascular disease, renal impairment, hepatic dysfunction, peptic ulcer disease, bleeding disorders, thrombocytopenia, substance use history 1
• Surgical History: Include dates and any pain-related complications 2
• Psychiatric History: Depression, anxiety, substance abuse history (critical for opioid prescribing) 1, 2

Current Medications

• Analgesics:

  • Opioids: specific agent, dose, frequency, total daily morphine milligram equivalents (MME) 1, 4
  • NSAIDs/COX-2 inhibitors: document specific agent and dose 1
  • Acetaminophen: daily dose 1

• Adjuvant Agents:

  • Anticonvulsants (gabapentin, pregabalin) 6
  • Antidepressants (tricyclics, SNRIs): specify agent and dose 6
  • Muscle relaxants (tizanidine, cyclobenzaprine) 4
  • Topical agents 6

• Other Medications: Anticoagulants, corticosteroids, nephrotoxic drugs, chemotherapy agents (relevant for NSAID safety) 1

Allergies and Adverse Reactions

• Document specific reactions: Distinguish true allergies from side effects or intolerances 1

Review of Systems

• Pain-Specific: Sleep disturbance (insomnia severity), mood changes, cognitive effects 2
• Medication Side Effects:
  • Gastrointestinal: nausea, vomiting, constipation (no bowel movement for 3 days requires intervention), epigastric pain, GI bleeding 1, 7
  • Neurologic: sedation, confusion, difficulty arousing from sleep, dizziness 1, 4
  • Renal: changes in urination, edema 1
  • Cardiovascular: new or worsening hypertension, chest pain 1

Physical Examination

• Vital Signs: Blood pressure (monitor for NSAID-induced hypertension), heart rate, respiratory rate 1

• Pain-Focused Exam:

  • Inspection: posture, gait, visible deformities 5
  • Palpation: tenderness, trigger points, muscle spasm 5
  • Range of motion: active and passive 5
  • Neurologic: sensory deficits, motor strength, reflexes 5
  • Functional assessment: observe patient performing relevant activities 2

• Mental Status: Level of alertness, orientation, signs of sedation or cognitive impairment 1

Pain Assessment Tools

• Standardized Measures:
  • Pain intensity: Visual Analog Scale (VAS) or Numerical Rating Scale (0-10) 4, 2
  • Functional impact: Pain Disability Index (PDI) 2
  • Psychological factors: Hospital Anxiety and Depression Scale (HADS), kinesiophobia (Tampa Scale for Kinesiophobia) 2
  • Quality of life: EQ-5D Index and EQ VAS 2
  • Sleep: Insomnia Severity Index (ISI) 2

Assessment and Problem List

• Primary Pain Diagnosis: Specific etiology (neuropathic, nociceptive, centrally mediated, mixed) 6, 5
• Contributing Factors: Psychological (anxiety, depression, catastrophizing), sleep disturbance, functional limitations 6, 2
• Medication-Related Issues: Side effects, inadequate analgesia, risk factors for toxicity 1, 7
• Risk Stratification:
  • High-risk features for NSAID complications: age ≥60 years, peptic ulcer history, alcohol use (≥2 drinks/day), anticoagulant use, organ dysfunction 1, 7
  • Opioid risk assessment: substance abuse history, psychiatric comorbidities 1

Management Plan

Pharmacologic Interventions

• Analgesic Adjustments:

  • For opioid-tolerant patients requiring dose increase: Calculate 10-20% of 24-hour requirement for breakthrough dosing; reassess at 60 minutes and increase by 50-100% if pain unchanged 4
  • For NSAID therapy: Use agent previously effective and tolerated; maximum ibuprofen 3200 mg/day in divided doses 1
  • Avoid combining NSAIDs: Never add a second NSAID to existing celecoxib or other NSAID therapy due to additive GI, renal, and cardiovascular toxicity 4
  • COX-2 inhibitors: Consider for patients at high GI risk (lower GI side effects, no platelet inhibition) 1
  • Nonacetylated salicylates: Alternative for patients with bleeding risk (choline magnesium salicylate 4.5-5 g/day or salsalate 2-3 g/day in divided doses) 1

• Adjuvant Medications:

  • For centrally mediated/functional pain: Start low-dose tricyclic antidepressant (amitriptyline or nortriptyline 10-25 mg at bedtime) as first-line 6
  • Alternative if TCA not tolerated: SNRI (duloxetine 30-60 mg daily) 6
  • For spasmodic pain: Anticholinergic antispasmodics (dicyclomine) more effective than direct smooth muscle relaxants 6

• Bowel Regimen: Mandatory prophylaxis for opioid-induced constipation 1

Non-Pharmacologic Interventions

• Physical Modalities: Physical therapy, occupational therapy, exercise programs 5
• Psychological Interventions: Cognitive behavioral therapy (CBT) initiated early to address catastrophizing and pain-related fear avoidance; explain gut-brain axis and central amplification mechanisms 6, 5
• Stimulation Techniques: TENS, acupuncture (when appropriate) 5

Interventional Procedures

• Nerve Blocks: Document indication, planned procedure, risks/benefits discussed 5
• Other Interventions: Epidural injections, radiofrequency ablation, spinal cord stimulation (as applicable) 5

Monitoring Plan

• Laboratory Monitoring:

  • Discontinue NSAIDs if BUN or creatinine doubles 1
  • Discontinue NSAIDs if liver function tests increase to 3× upper limit of normal 1
  • Discontinue NSAIDs if new or worsening hypertension develops 1

• Pain Reassessment: Reassess pain intensity at each contact using numerical rating scale 4

• Adverse Effect Monitoring: Nausea, dizziness, drowsiness, constipation, sedation 4

• Functional Outcomes: Track improvements in activities of daily living and quality of life 2

Patient Education (Mandatory Written Documentation)

The following must be reviewed with patient/family and provided in written form with date: 1

• Medication List: Each medication prescribed with description of purpose and specific instructions for dosing and timing 1

• Potential Side Effects: What to expect and management strategies 1

• Discontinued Medications: Clear list of medications to stop 1

• Key Educational Messages:

  • Pain relief is medically important; no benefit to suffering 1
  • Regular analgesic schedule improves control of persistent pain 1
  • Multiple treatment options available if current regimen ineffective 1
  • Take potent analgesics only as prescribed; do not self-adjust without provider consultation 1, 7
  • Controlled substances must be properly safeguarded at home 1
  • Do not mix medications with alcohol or illicit substances 1
  • For patients with substance abuse history: addiction rarely occurs when opioids used appropriately for pain 1
  • Medications remain effective if needed later (address tolerance concerns) 1

• When to Contact Provider (specific instructions): 1

  • Problems obtaining or taking medications 1
  • New pain, changed pain, or pain unrelieved by medication 1
  • Nausea/vomiting preventing eating for one day 1
  • No bowel movement for 3 days 1
  • Difficulty arousing patient from sleep during daytime 1
  • Confusion or altered mental status 1
  • Original symptoms return after medication discontinuation 7
  • Signs of GI bleeding 7

• Safety Warnings:

  • Regulations regarding operation of machinery/motor vehicles while taking sedating medications 1
  • Contraindications to tramadol: seizure history, respiratory compromise, liver/renal impairment 4

• Provider Contact Information: Telephone numbers to reach appropriate healthcare provider 1

Referrals

• Specialty Consultations: Pain psychology, physical medicine and rehabilitation, interventional pain, addiction medicine (as indicated) 5, 2

Follow-Up Plan

• Specific Timeline: Schedule phone call or visit within 1-2 weeks to assess symptom response and medication tolerance 7
• Long-Term Monitoring: Plan for ongoing reassessment of pain control, functional status, and treatment-related complications 2

Critical Pitfalls to Avoid

• Never prescribe opioids for chronic GI pain: Creates narcotic bowel syndrome and worsens outcomes 6
• Never combine multiple NSAIDs: Significantly increases serious adverse events without additional benefit 4
• Never assume pain assessment without patient report: Providers cannot determine pain severity without patient communication 1
• Never omit written discharge instructions: Verbal education alone is insufficient for safe pain management 1