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Chronic Pain Consult Note
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Finished note
Example — generated by Notat from a sample visit
Reason for consultation: Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope. Assessment: Stable clinical presentation requiring further outpatient evaluation. Plan: Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Breathlessness: Progressive exertional breathlessness over two months
denials of symptoms
Denies: Associated symptoms: No chest pain at rest or syncope
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
medications
Current treatment: Continue established medicines pending review
plan
Investigations: Outpatient investigations arranged
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
Chronic Pain Specialist Consult Note Patient Identification: [Patient name, age, gender, with a history of..., presenting with chronic pain in..., duration of symptoms, relevant comorbidities] History of Present Illness: [Detailed description of pain including location, quality, intensity, duration, frequency, aggravating and relieving factors, associated symptoms, impact on function and quality of life] [Previous treatments tried and response] [Relevant psychosocial context] Past Medical History: (hyphenated list) - [Chronic conditions] - [Previous surgeries] - [Relevant hospitalizations] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - [Include pain medications, adjuncts, and other relevant therapies] Allergies: (hyphenated list) - [Drug allergies] - [Other allergies] Family History: (hyphenated list) - [Relative: Condition or pertinent diagnosis] - [Hereditary pain syndromes if relevant] Social History: (hyphenated list) - [Tobacco: type, amount, duration, quit date if applicable] - [Alcohol: type, amount, frequency] - [Recreational substances: type, amount, frequency] - [Occupation: current job, exposures, impact of pain on work] - [Living situation: who lives with patient, home environment] - [Support systems] Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [General appearance] - [Musculoskeletal: inspection, palpation, range of motion, tenderness, swelling, deformity] - [Neurological: motor, sensory, reflexes, gait, coordination] - [Other relevant systems] Investigations: (hyphenated list) - [Imaging results with units] - [Laboratory results with units] - [Other diagnostic tests] Assessment & Plan: [One-sentence patient summary including age, sex, pain diagnosis, and impact] #) [Pain diagnosis as a numbered item] (hyphenated list with each corresponding plan item on a new line) - [Further investigations planned or ordered] - [Medication adjustments or recommendations] - [Non-pharmacological therapies (e.g., physical therapy, psychological interventions)] - [Interventional procedures (e.g., injections, nerve blocks)] - [Counselling discussion] - [Referrals sent (e.g., physiotherapy, psychology, other specialties)] - [Follow up plan] - [Return precautions]
Shared by
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Dr. Laura Conti
Dermatologist, Italy
How it works in Notat
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