Interventional Pain Pre-Procedure Evaluation Note

Date/Time of evaluation: [Date and time]

Author: [Name, credentials, role]

Location: [Clinic/procedure area and facility]

Encounter Type: Pre-procedure evaluation — [same-day update / pre-op clinic visit]

Planned Procedure(s): [Planned interventional pain procedure name(s)]

Procedure Date: [Procedure date] (Include only if different from note date)

Referring Clinician: [Referring clinician name and specialty] (Include only if applicable)

Chief Complaint

[Primary pain complaint: location, quality, radiation] — [Purpose of visit] (1–2 sentences; may include a brief patient quote if it clarifies the complaint)

Interval History

(Include this section only for a same-day update or when a meaningful interval has passed since the last comprehensive pain visit.)

[Interval symptom changes, new or progressive neurologic deficits, red flags (fever, new bowel/bladder dysfunction, saddle anesthesia), interim treatments and responses, new imaging findings, new diagnoses or events affecting care] (If no interval changes, state explicitly: "No interval change in symptoms; no new neurologic deficits; no fever or signs of infection.")

Medical Necessity

(This section should read as a coverage-criteria narrative demonstrating why the intervention is indicated.)

• Working diagnosis and suspected pain generator: [Diagnosis with laterality, level/region, and pathophysiology]
• Pain duration: [Onset date or timeframe]
• Baseline pain severity: [Score] on [scale name, e.g., NRS 0–10]
• Baseline function: [Validated instrument score (e.g., ODI, PROMIS, Roland-Morris) and/or structured ADL limitations] (Provide sufficient detail for post-procedure comparison.)
• Conservative management attempted: (List each modality with duration, adherence/tolerance, and outcome; quantify when possible)
  • [Physical therapy: frequency/duration, adherence, response]
  • [Medications: class, dose, duration, response, side effects]
  • [Home exercise/activity modification: details and response]
  • [Other non-procedural treatments: modality, duration, response]
  • (If conservative care contraindicated or not tolerated, document rationale)
• Prior interventional history: (Include only if applicable for same region)
  • [Procedure name/date, target levels/sides]
  • [Clinical response: percent relief and duration of benefit]
  • [Adverse events or complications]
  • [Justification for repeat or different-level procedure]
• (If required baseline details are unavailable, document reason and plan to obtain before proceeding)

Pertinent Medical History

• Bleeding risk: [Coagulopathy, liver disease, thrombocytopenia, history of bleeding]
• Infection risk: [Immunosuppression, poorly controlled diabetes, active infection, skin issues near entry site]
• Positioning/sedation risk: [OSA, severe obesity, cardiopulmonary disease, inability to lie prone/supine, prior anesthesia issues]
• Steroid considerations: [Diabetes control, glaucoma, recent systemic/local steroid exposure] (Include only if steroid planned)
• Relevant medications: [Anticoagulants/antiplatelets; diabetes medications if steroid planned; chronic opioids/benzodiazepines; immunosuppressants or biologics — include agent and dose for each]
• Allergies: [Drug/agent and reaction type/severity; emphasize local anesthetics, steroids, skin prep agents, contrast, latex] (If no known drug allergies, document "NKDA")

Anticoagulation Management

(Include this section only if the patient is taking anticoagulants or antiplatelets.)

• Agent: [Name] — Dose: [Dose/route] — Indication: [Indication] — Prescriber: [Name/Specialty]
• Last dose: [Date/Time] — Hold duration: [Days/hours] — Restart plan: [Timing post-procedure]
• Bridging: [Bridging details / not applicable]
• Labs: [INR, platelet count, anti-Xa with dates as clinically indicated]
• Counseling: Patient counseled on bleeding vs thrombosis tradeoff and agreed to the plan.

(If the patient cannot safely hold therapy, summarize shared decision-making and plan modification: [postpone / lower-risk procedure / proceed with modifications] with rationale.)

Imaging Review

• Modality and date: [MRI / CT / X-ray / Ultrasound], [date]
• Key findings: [Level-specific pathology: stenosis, disc herniation, facet arthropathy, etc.]
• Concordance statement: [Explicit linkage of imaging findings with symptoms and examination]
• Target selection rationale: [Rationale for target level(s), side, and approach]

(If images not directly reviewed, note whether report vs images were reviewed and plan to obtain images before proceeding.)

Review of Systems

(Brief and focused on safety-relevant items only)

• Fever/chills: [positive / negative]
• Skin infection or rash at potential entry site: [positive / negative]
• New bowel/bladder dysfunction or saddle anesthesia: [positive / negative]
• Progressive weakness or new neurologic deficits: [positive / negative]
• Bleeding/bruising symptoms: [positive / negative / N/A] (Include if on anticoagulation)
• Pregnancy status: [status / N/A] (Include if fluoroscopy or CT planned)

Physical Examination

• Vitals: [BP, HR, RR, Temp, SpO2, Weight, Height, BMI]
• General/gait: [General appearance, distress level, gait pattern, assistive device use]
• Neurologic: [Strength by myotome, sensation by dermatome, reflexes, straight leg raise, focal deficits]
• Spine/MSK: [Tenderness, range of motion, facet loading, SI maneuvers, other provocative tests relevant to suspected pain generator]
• Entry-site skin: [Inspection of planned entry site(s): no rash/cellulitis/wound, or describe abnormality]

(If examination is limited, document the limitation and how it affects decision-making.)

Assessment

1. [Diagnosis with laterality and level/region] — [Brief supporting evidence: symptoms, exam, imaging correlation; pertinent exclusions]
2. (Add additional problems only if directly relevant to the planned intervention)

Procedure Plan

• Procedure and intent: [Procedure name] — [diagnostic / therapeutic]
• Target(s): [Region, level(s), laterality, number of levels]
• Approach: [Interlaminar / transforaminal / medial branch / SI joint / other]
• Image guidance: [Fluoroscopy / CT / Ultrasound] — Contrast: [planned / not planned]
• Planned medications: [Local anesthetic] [± Steroid type] [± Other] (Exact dosing to be documented in Procedure Note)
• Special precautions: [Implanted device precautions, antibiotic prophylaxis, contrast allergy premedication, etc.] (Include only if applicable)
• Expected outcome goal: [Measurable goal, e.g., "≥50% pain relief to enable PT participation"]
• Safety verification: Correct patient, procedure, site, side, and level will be verified with site marking and time-out per facility protocol.

Sedation Plan

(Include this section only if sedation beyond local anesthetic is planned.)

• Planned sedation level: [minimal / moderate]
• Sedation risk factors: [OSA, prior complications, airway concerns, comorbidities]
• NPO status: [Confirmed] — Escort/driver: [Arranged]
• Pre-sedation reassessment: Patient will be reassessed immediately prior to sedation.

Informed Consent

Risks, benefits, and alternatives discussed with the patient. Risks include infection, bleeding, nerve injury, dural puncture/headache, [steroid-related effects], [contrast reaction], and radiation exposure. Alternatives include continued conservative management, medication adjustments, surgical referral when indicated, and no treatment. Patient had the opportunity to ask questions and expressed understanding. (Include steroid and contrast risks only if applicable. If signature captured in Procedure Note, state this.)

Follow-up Plan

• Pre-procedure instructions reviewed: [Medication holds, diabetes guidance if steroid planned, arrival logistics]
• Post-procedure follow-up: [Timeframe] via [in-person / telehealth / phone]
• Outcome measurement: Pain and function will be reassessed using the same baseline scale(s) documented above.