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)
    Associated symptoms
    Modifying factors
    Previous treatments that helped
    Previous treatments that did not help
Review of systems
    Mental health problemsYES/NO
    Recent thoughts of suicideYES/NO
    Adequate sleepYES/NO
    Paralysis or loss of functionYES/NO
    Change in weightYES/NO
    Previous history of cancerYES/NO
    Impairment to visionYES/NO
    Dry mouthYES/NO
    Witnessed apneaYES/NO
    Changes in sexual functionYES/NO
Past medical history: see below
Past surgical history: see below
Family history
    Alcohol or drug abuseYES/NO
Social history
    Smoking currentlyYES/NO
    Alcohol use everYES/NO
    Illegal drug useYES/NO
    Marijuana useYES/NO
    Currently abusedYES/NO
    Currently workingYES/NO
    Living situation changesYES/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
    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)?
    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.