Pain Management Documentation Guide 2026

PAIN MANAGEMENT INITIAL CONSULTATION

PATIENT: [Name], [Age] y/o [M/F]
DATE: [Date]
REFERRING PROVIDER: [Name]

CHIEF COMPLAINT: [Patient's description of pain problem]

PAIN HISTORY:
Location: [Primary site(s) and radiation pattern]
Onset: [Date/circumstances of pain onset]
Duration: [How long patient has had pain]
Quality: [Sharp, dull, burning, aching, stabbing, shooting, throbbing, etc.]
Severity: [0-10 scale] Currently: ___/10, Average: ___/10, Best: ___/10, Worst: ___/10
Timing: [Constant, intermittent, breakthrough episodes]
Aggravating Factors: [What makes pain worse]
Alleviating Factors: [What makes pain better]

PREVIOUS TREATMENTS:
Medications Tried:
1. [Medication] - [Dose] - [Duration] - [Outcome/reason for discontinuation]
2. [...]

Physical Therapy: [Y/N, duration, outcome]
Injections: [Type, location, date, % relief, duration]
Surgery: [Type, date, outcome]
Alternative Therapies: [Acupuncture, chiropractic, massage, etc.]

CURRENT MEDICATIONS:
[List all medications with doses and frequencies]
Pain Medications: [...]
Other Medications: [...]
Allergies: [Medication allergies and reactions]

FUNCTIONAL IMPACT:
Work Status: [Full-time, part-time, disabled, modified duty, unemployed]
Activities of Daily Living: [Independent, needs assistance with: ___]
Sleep: [Hours per night, difficulty falling/staying asleep, quality]
Mood: PHQ-9 score: ___ ([None/Mild/Moderate/Moderately Severe/Severe])
Exercise: [Type, frequency, limitations]
Social Impact: [Activities stopped, relationships affected]

SUBSTANCE USE HISTORY:
Tobacco: [Current/former/never, pack-years]
Alcohol: [Drinks per week]
Illicit Drugs: [Current/past use, substances, last use]
History of Substance Use Disorder: [Y/N, details, treatment, remission length]

PHYSICAL EXAMINATION:
General: [Appearance, mood, distress level]
[Focused exam of pain region - spine, joints, neuro as appropriate]
[Include relevant neurological exam if neuropathic pain]

IMAGING REVIEW:
[Review of X-rays, MRI, CT with findings relevant to pain]

ASSESSMENT:
1. [Primary pain diagnosis] ([ICD-10 code])
   - [Pain type: nociceptive, neuropathic, mixed, nociplastic]
   - [Severity: mild, moderate, severe based on pain scores and functional impact]

2. [Secondary diagnoses]

3. Functional Status: [Baseline function level]

OPIOID RISK ASSESSMENT (if considering opioid therapy):
- Opioid Risk Tool Score: ___ ([Low <4, Moderate 4-7, High >7])
- Risk Factors: [List relevant factors]
- Protective Factors: [List relevant factors]
- Overall Risk Level: [LOW / MODERATE / HIGH]

PDMP Review: [Date checked, findings]

TREATMENT PLAN:
Goals:
1. Pain reduction to ___/10
2. Functional goals: [Specific, measurable - return to work, walk X distance, sleep through night, etc.]
3. [Additional goals]

Medications:
1. [Medication, dose, frequency, indication]
2. [...]
[Include MME calculation if opioid prescribed]

If Initiating Opioid Therapy:
- Informed consent: Completed and signed [Date]
- Treatment agreement: Signed [Date]
- Naloxone: Prescribed, education provided
- Monitoring plan: UDT at baseline and every [interval], PDMP every [interval]

Non-Pharmacologic:
- Physical therapy: [Plan]
- Interventional procedures: [Considering ___]
- Behavioral health: [CBT, pain psychology, biofeedback]
- Exercise/activity modification: [Recommendations]

Referrals:
- [Specialists as needed]

Follow-up: [Timeframe]
- Sooner if: [Red flags requiring earlier follow-up]

Patient Education:
- [Topics discussed: safe storage, side effects, when to call, etc.]

Time spent: [Total visit time], >50% counseling and coordination

[Provider signature]
[Date/Time]