Chronic Pain Follow-Up Visit Note (In-Person/Telehealth)

Date of Service: [Date of service]

Patient: [Patient name and identifier]

Provider: [Provider name, credentials]

Visit Type: [In-Person / Telehealth]

Telehealth Details: [Modality (audio-video / audio-only with rationale if audio-only); patient location (city, state); consent obtained; other participants if any; exam limitations] (Include only for telehealth visits.)

Chief Complaint

[Reason for this chronic pain follow-up visit]

Interval History

[Anchoring sentence stating chronic pain condition(s), time since last visit, and patient's current priority concern. Narrative of interval changes in pain (location, pattern, severity, triggers); current pain and function scores with comparison to prior values and dates; functional goals and progress; response to treatments since last visit (medications, physical therapy, procedures, self-management); adverse effects or tolerability issues; explicit documentation that red flags were queried (new neurologic deficits, bowel/bladder changes, fever, unexplained weight loss, new trauma).] (Use 1–2 paragraphs. Include brief patient quotes only when adding clinical clarity. If a required score was not obtainable, document "Not obtained" with reason.)

Objective

Vitals: [Measured values; for telehealth, patient-reported values or "not available"]

Exam: [Focused musculoskeletal and neurologic findings relevant to pain complaint] (For telehealth, document observable elements and explicitly note limitations.)

Data: [Relevant labs, imaging, or records reviewed this visit] (Omit if none reviewed.)

Assessment

[Problem 1]: [Diagnosis] — [improved / stable / worse]. [Key findings supporting status; safety-relevant contributors (mood, sleep, substance use, high-risk co-medications) when they inform reasoning; differential diagnosis only if active uncertainty affects the plan.]

[Problem 2]: [Additional problems as needed, following same format.]

Plan

[Problem 1]: [Medication actions with explicit dose transitions and dates; nonpharmacologic interventions; referrals and orders; patient education including side effects and warning signs for earlier contact.] (Use action verbs: Continue/Start/Stop/Increase/Decrease/Refer/Order.)

Controlled Substance Documentation: [PDMP review date and findings; most recent toxicology result and interpretation if obtained; naloxone status (offered/prescribed/declined/not indicated with reason); brief benefit-risk statement.] (Include only if prescribing, continuing, or changing controlled substances. Document only what was actually performed or discussed.)

[Problem 2]: [Plan for additional problems as needed.]

Follow-Up: [Specific timeframe and explicit triggers for earlier return] (Avoid "return PRN" without defined parameters.)