Template for Chronic Pain Management Structured Subjective Objective Assessment Plan (SOAP) Note
| Chief complaint: chronic pain management visit | |
| Controlled substance database last reviewed | |
| Urine drug screen last obtained | |
| Pain contract signed | |
| History of present illness (one or more chronic pain disorders) | |
| Location | |
| Intensity | |
| Quality | |
| Duration | |
| Frequency | |
| Associated symptoms | |
| Modifying factors | |
| Previous treatments that helped | |
| Previous treatments that did not help | |
| Review of systems | |
| Mental health problems | YES/NO |
| Recent thoughts of suicide | YES/NO |
| Adequate sleep | YES/NO |
| Paralysis or loss of function | YES/NO |
| Incontinence | YES/NO |
| Fever | YES/NO |
| Change in weight | YES/NO |
| Previous history of cancer | YES/NO |
| Impairment to vision | YES/NO |
| Dry mouth | YES/NO |
| Syncope | YES/NO |
| Witnessed apnea | YES/NO |
| Constipation | YES/NO |
| Itching | YES/NO |
| Changes in sexual function | YES/NO |
| Past medical history: see below | |
| Past surgical history: see below | |
| Family history | |
| Suicide | YES/NO |
| Alcohol or drug abuse | YES/NO |
| Social history | |
| Smoking currently | YES/NO |
| Alcohol use ever | YES/NO |
| Illegal drug use | YES/NO |
| Marijuana use | YES/NO |
| Currently abused | YES/NO |
| Currently working | YES/NO |
| Living situation changes | YES/NO |
| Brief Pain Inventory Short Form scores | |
| Roland Disability score | |
| SOAPP-R score | |
| Zung Depression raw score | |
| Physical examination | |
| Patient is alert and in no apparent distress | |
| Gait is | |
| Strength is /5 with flexion and extension at | |
| Deformity not present | |
| Assessment | |
| Is patient meeting previous goal markers for pain control? | |
| What are patient's new goals markers for pain control? | |
| Is there evidence for improvement in function? | |
| What will be planned goal for improvement in function next visit? | |
| Are there signs of diversion? | |
| Are there adverse effects of medication? | |
| Does the risk versus benefit ratio favor continuing narcotic pain medication? | |
| Has patient tried safer options for pain control (NSAID, ACET, Tramadol, Lidocaine, topical NSAID, or PT)? | |
| Plan | |
| Patient given handout on prescription drug abuse | |
| Patient given handout on safe medication disposal | |
| Does patient require more extensive monitoring? Pill counts, urine drug screens. |
NSAID, Nonsteroidal Anti-Inflammatory Drugs; ACET, Acetaminophen; PT, Physical Therapy.