SOAP Note Example
Pain Management SOAP Note Example
Below is a complete SOAP note example for a pain management visit with an adult patient receiving multimodal treatment for chronic low back pain, including a lumbar epidural steroid injection and ongoing medication management. This example demonstrates proper documentation of pain assessment scales, opioid risk stratification, PDMP verification, procedural documentation, and a comprehensive treatment plan.
Complete Pain Management Note
SUBJECTIVE:
Patient is a 54-year-old male presenting for a scheduled pain management follow-up and lumbar epidural steroid injection. Primary diagnosis: chronic low back pain with left L5 radiculopathy secondary to L4-L5 disc herniation (MRI 01/15/2026 confirmed a left paracentral disc protrusion at L4-L5 with moderate left lateral recess stenosis and contact of the traversing left L5 nerve root). Duration of symptoms: 8 months, with the radicular component worsening over the past 3 months despite conservative management including physical therapy (completed 12 sessions), oral NSAIDs, and a course of oral methylprednisolone. Current pain: patient reports constant low back pain rated 7/10 on the Numeric Rating Scale (NRS) with intermittent sharp, shooting pain radiating from the left buttock down the posterior left thigh to the lateral calf, rated 8/10 at its worst. PEG scale scores: Pain intensity average over the past week 7/10, Enjoyment of life interference 8/10, General activity interference 7/10 (PEG average 7.3/10). Pain is worse with prolonged sitting (greater than 20 minutes), bending forward, and transitioning from sitting to standing. Partially relieved by lying supine with knees elevated and by his current medication regimen. Currently taking hydrocodone-acetaminophen 5/325 mg one tablet every 6 hours as needed — reports taking 3-4 tablets daily with moderate relief lasting approximately 4 hours per dose. Also taking duloxetine 60 mg daily (initiated 6 weeks ago) — reports mild improvement in the baseline aching quality of the pain. Reports difficulty sleeping due to pain, averaging 4-5 hours per night, waking 2-3 times when he rolls onto his left side. Functional limitations: unable to sit through a full workday at his desk job without standing breaks every 15-20 minutes, unable to exercise (previously walked 2 miles daily), difficulty with ADLs including putting on shoes and socks, and has stopped driving distances greater than 30 minutes. Mood: reports frustration and low mood related to functional decline — PHQ-2 score 3 (positive screen). Opioid Risk Tool (ORT) score: 3 (low risk). Denies any history of substance abuse, personal or family. Denies aberrant medication-taking behaviors — no early refill requests, no lost prescriptions, no use of opioids from other sources. Last urine drug screen (02/15/2026): positive for hydrocodone and hydromorphone (expected metabolite), negative for all other substances including illicit drugs. PDMP checked today (03/01/2026): sole prescriber for controlled substances confirmed, last fill hydrocodone-acetaminophen 5/325 mg #120 on 02/15/2026 — pill count consistent with reported usage.
OBJECTIVE:
Vital signs: blood pressure 134/82 mmHg, heart rate 74 bpm, respiratory rate 14, SpO2 98% on room air, weight 210 lbs (95.5 kg), height 5 feet 11 inches, BMI 29.3. General: alert, oriented, in no acute distress at rest; moves cautiously when transitioning from seated to standing position with guarded lumbar motion. Musculoskeletal examination: lumbar spine — flattened lordosis, paravertebral muscle spasm bilateral (left greater than right), tenderness to palpation over the L4-L5 interspinous space and left paraspinal musculature. Active ROM: flexion 30 degrees (limited by pain and left leg radicular symptoms), extension 15 degrees (limited by pain), lateral flexion 20 degrees bilateral. Straight leg raise: positive on the left at 35 degrees reproducing radicular pain to the lateral calf, negative on the right. Crossed straight leg raise: negative. Slump test: positive on the left reproducing concordant radicular symptoms. Motor examination: left hip flexion 5/5, left knee extension 5/5, left ankle dorsiflexion 4/5 (subtle weakness compared to right 5/5), left extensor hallucis longus 4/5 (subtle weakness compared to right 5/5), left ankle plantarflexion 5/5, left hip abduction 5/5. Right lower extremity motor strength 5/5 throughout. Sensory examination: decreased light touch and pinprick sensation over the left lateral calf and dorsum of the left foot (L5 dermatome) compared to the right; intact sensation in all other dermatomes bilaterally. Deep tendon reflexes: patellar 2+ bilateral, Achilles 2+ right, 1+ left (diminished). No clonus. Gait: antalgic with shortened left stance phase, no foot drop. Procedure performed: left L4-L5 interlaminar epidural steroid injection under fluoroscopic guidance. Informed consent obtained after discussion of risks (infection, bleeding, dural puncture, nerve injury, allergic reaction, temporary increase in pain), benefits, and alternatives. Time-out performed confirming patient identity, procedure, and laterality. Patient positioned prone on fluoroscopy table with abdominal bolster to reduce lumbar lordosis. Skin prepped with chlorhexidine and draped in sterile fashion. Local anesthesia: 1% lidocaine 5 mL to subcutaneous tissue at the L4-L5 interlaminar space. An 18-gauge Tuohy needle was advanced under intermittent anteroposterior fluoroscopic guidance to the left L4-L5 interlaminar space. Loss of resistance to air confirmed entry into the epidural space. Contrast injection (Omnipaque 240, 1 mL) confirmed epidural spread with no intravascular, intrathecal, or subdural pattern. Injection: dexamethasone 10 mg (preservative-free) combined with 0.25% bupivacaine 4 mL, total injectate volume 5 mL, injected slowly over 60 seconds. Needle removed intact. No immediate complications. Post-procedure vital signs stable: blood pressure 130/78, heart rate 72, SpO2 99%. Patient monitored for 20 minutes post-procedure — no adverse effects, no new neurological deficits. Discharged ambulatory with driver.
ASSESSMENT:
Chronic low back pain with left L5 radiculopathy secondary to left paracentral L4-L5 disc herniation with lateral recess stenosis, confirmed on MRI 01/15/2026. The clinical presentation — positive left SLR at 35 degrees, concordant left slump test, subtle left ankle dorsiflexion and EHL weakness (4/5), diminished left L5 dermatomal sensation, and diminished left Achilles reflex — is anatomically consistent with left L5 nerve root compression. Symptoms remain moderate to severe (NRS 7/10, PEG average 7.3) despite 8 months of conservative management including completed physical therapy, oral anti-inflammatory therapy, and initiation of duloxetine. The patient has failed adequate conservative treatment, meeting the criteria for interventional management. Epidural steroid injection performed today without complication — expected onset of anti-inflammatory benefit is 3-7 days with peak effect at 2-3 weeks. The subtle motor deficit in the L5 distribution warrants close monitoring — any progression would necessitate urgent surgical consultation. Opioid therapy is currently appropriate at a low dose with low risk stratification (ORT 3), confirmed PDMP compliance, congruent urine drug screen, and no aberrant behaviors. PHQ-2 screen is positive — warrants full PHQ-9 at follow-up to evaluate for comorbid depression, which is common in chronic pain and influences treatment outcomes. Current multimodal approach (interventional, pharmacologic, and rehabilitative) is appropriate and should continue.
PLAN:
Post-injection instructions provided: ice to injection site 15 minutes every 2 hours for the first 24 hours, avoid submerging injection site in water (no baths, pools, or hot tubs) for 48 hours, avoid strenuous activity for 48 hours, expect possible temporary increase in pain for 1-3 days before steroid benefit begins. Continue current medications: hydrocodone-acetaminophen 5/325 mg one tablet PO every 6 hours PRN (maximum 4 tablets per day), duloxetine 60 mg PO daily, and OTC acetaminophen is not to exceed a combined total of 2 grams per day including the acetaminophen in the hydrocodone combination product. Follow-up in 3 weeks to assess injection response — if greater than 50% pain relief sustained for 3 or more weeks, will plan a second injection in the series (up to 3 injections per 12-month period). If less than 50% relief, will discuss alternative approaches including transforaminal epidural approach, referral for surgical consultation, or trial of spinal cord stimulation. Resume physical therapy focusing on lumbar stabilization and nerve gliding techniques — new referral placed for 2x/week for 6 weeks, to begin 1 week after injection once initial steroid effect has onset. Administer PHQ-9 at follow-up visit — if score indicates moderate or greater depression, discuss referral to behavioral health for pain psychology and cognitive behavioral therapy for chronic pain. Opioid management: continue current dose with monthly PDMP checks and urine drug screening every 3 months per clinic opioid agreement (signed 01/20/2026, on file). If pain improves with injection series, will initiate a gradual taper plan for hydrocodone with a goal of opioid discontinuation or dose reduction. Weight management discussed — BMI 29.3 contributes to mechanical lumbar loading; referral to nutrition counseling offered, patient deferred to after injection response is assessed. Next appointment: 03/22/2026.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Pain management subjective documentation must include validated pain assessment scales — the Numeric Rating Scale for current pain intensity and the PEG scale (Pain, Enjoyment, General activity) for functional impact. Document the specific pain character, distribution, aggravating and relieving factors, and the response to each current treatment modality. For patients on opioid therapy, document the Opioid Risk Tool score, adherence history (early refills, lost prescriptions, outside sources), most recent urine drug screen results, and PDMP verification with the date checked and findings. This creates the medicolegal record that opioid prescribing is being monitored per guideline-concordant care. A PHQ-2 screen captures the mood component that directly influences pain outcomes.
Objective
The objective section must include a focused musculoskeletal and neurological examination that correlates with the imaging findings — document specific provocative tests (SLR, slump test with the angle at which symptoms are reproduced), motor strength in individual myotomes with side-to-side comparison, dermatomal sensory testing, and reflex grading. For interventional procedures, document the full procedural note within the objective section: informed consent, time-out, patient positioning, sterile technique, needle type and approach, fluoroscopic confirmation, contrast pattern, injectate composition and volume, and post-procedure monitoring with vital signs. This level of procedural documentation is required for medicolegal compliance and insurance reimbursement of fluoroscopically guided injections.
Assessment
The pain management assessment must synthesize the clinical examination, imaging correlation, validated outcome measures, treatment response history, and opioid risk profile into a cohesive clinical narrative. Explicitly state that the patient has failed adequate conservative treatment when justifying interventional procedures — insurance prior authorization and peer review depend on this documentation. Identify motor deficits that serve as red flags requiring closer surveillance or surgical referral. Comment on the appropriateness of continued opioid therapy by referencing the risk stratification, monitoring compliance, and clinical indication. Address comorbid conditions such as depression that influence the pain experience and treatment response.
Plan
Pain management plans must define clear response criteria for interventional procedures — for example, greater than 50% pain relief sustained for 3 or more weeks qualifies the patient for a repeat injection, and less than 50% relief triggers a change in approach. Document specific post-procedure instructions, medication management with attention to combined acetaminophen limits, physical therapy referrals timed around the injection schedule, and follow-up intervals. For patients on chronic opioid therapy, reference the signed opioid agreement, specify the PDMP and urine drug screen monitoring schedule, and outline taper goals if the interventional treatment is successful. Include escalation and de-escalation criteria so the treatment pathway is transparent and defensible.
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