Pain Management Progress Note (SOAP)

Date/Time: [Date and time of encounter]

Encounter Type: [New / Follow-up]

Clinician: [Name, credentials]

Chief Reason for Visit: [Primary reason stated by patient or referral source]

Allergies: [Allergies / NKDA]

Subjective

[Interval history since last visit] (Summarize changes in pain status, response to prior treatments, recent procedures or medication adjustments, and any new events or diagnoses.)

[Pain characteristics] (Describe location(s), quality, severity, temporal pattern, radiation, exacerbating/relieving factors, and associated symptoms. Combine into a coherent narrative.)

[Functional impact] (Document effect on ADLs, mobility, sleep, mood, work, and quality of life. Include a brief patient quote capturing chief concern or functional goal when clinically useful.)

Pain/Function Scores: [Tool used, e.g., PEG, PROMIS, BPI] [Current scores with timeframe specified] [Comparison to prior scores with date] (Include at least one pain intensity and one function/interference measure.)

Medication Experience: [Current analgesic regimen] [Adherence] [Perceived efficacy] [Side effects] (For controlled substances, include perceived functional benefit and any safety concerns reported.)

Red Flag Screening: [Screened for: progressive weakness, bowel/bladder changes, saddle anesthesia, fever, unexplained weight loss] [Findings: present / absent / not assessed with reason]

Objective

Vitals/Appearance: [Relevant vitals] [General appearance and distress level] [Alertness if on sedating medications] [Gait and assistive devices if observed]

Exam: [Focused musculoskeletal and neurologic examination pertinent to pain complaint] (Document inspection, palpation, range of motion, provocative maneuvers with results, strength, sensation, and reflexes as relevant. State what was examined and findings. If exam deferred, state reason. Do not infer normal findings for areas not examined.)

Data Reviewed: [Imaging, labs, EMG/NCV, outside records with dates and key findings] (Include only studies reviewed today.)

Opioid Monitoring: [PDMP review date and relevant findings] [Toxicology test date, type, results, interpretation] [Controlled substance agreement status] (Include when controlled substances are prescribed or continued.)

Assessment

[One-sentence clinical summary framing primary pain generator(s), chronicity, and functional impact]

1. [Problem 1 - Working diagnosis/pain generator]: [Key supporting history and exam findings] [Pertinent data supporting diagnosis] [Functional impact severity tied to PRO scores]

2. [Problem 2 - Working diagnosis/pain generator]: [Key supporting history and exam findings] [Pertinent data supporting diagnosis] [Functional impact severity tied to PRO scores] (Add additional problems as needed.)

Opioid Therapy Assessment: [Current opioid(s), total daily dose, MME] [Documented functional benefit] [Risk factors present] [Synthesis of PDMP/toxicology/behavioral observations] [Clinical decision: continue / modify / taper] [Rationale] (Include when opioids are prescribed or continued.)

[Behavioral health and substance use considerations] (Document relevant factors affecting care using non-stigmatizing language and planned actions. Omit if not applicable.)

Plan

1. [Problem 1]:

   • Non-pharmacologic: [PT/OT focus, home exercise, behavioral interventions, sleep optimization, activity pacing as applicable]
   • Medications: [Drug, dose, route, frequency, duration] [Rationale linked to pain generator] [Safety monitoring plan]
   • Opioid Plan: [Drug, dose, quantity, directions, indication] [Risk mitigation: PDMP reviewed, toxicology plan, naloxone offered/prescribed, counseling provided] [If tapering: rationale, pace, withdrawal support] (Include when prescribing opioids.)
   • Procedures: [If planned: target diagnosis, medical necessity, risks/benefits discussed] [If performed today: brief summary, see Procedure Note below]
   • Referrals/Orders: [Imaging, specialist referrals, care coordination with rationale]
   • Follow-up: [Timeframe] [Reassessment targets: PRO measures, adverse effects, functional goals] [Return precautions]

2. [Problem 2]: (Repeat structure as needed.)

Procedure Note

(Include only when a procedure was performed today.)

Procedure: [Name, laterality, levels]

Indication: [Diagnosis and rationale]

Consent: [Obtained; risks/benefits/alternatives reviewed]

Time-out: [Correct patient, procedure, site verified]

Technique: [Position, sterile prep, anesthesia, guidance modality, approach, needle details, injectate (drug, concentration, volume), target structures]

Complications: [None / description]

Outcome: [Tolerance, pre/post pain scores, immediate neuro status]

Disposition: [Discharge status, activity restrictions, warning signs, follow-up]