Pain Medicine Consult

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™

Template

Pain Consult Note

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Structure symptoms and associated information into distinct paragraphs. Use full sentences and formal clinical language)
- [Onset, duration, and progression of pain]
- [Location, character, intensity (e.g., 0-10 scale), radiation]
- [Aggravating and relieving factors]
- [Associated symptoms]
- [Previous treatments and response]
- [Impact on function, sleep, mood, and quality of life]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions, especially those related to pain]

Past Surgical History:
(hyphenated list)
- [Relevant surgical procedures]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Oxycodone 5 mg oral q6h PRN)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Father: chronic back pain)

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]
- [Living situation: who lives with patient, home environment]
- [Support systems]

Pain History:
(hyphenated list)
- [Pain onset and course]
- [Pain descriptors (e.g., burning, stabbing, throbbing)]
- [Pain intensity (e.g., average, worst, best)]
- [Temporal pattern (e.g., constant, intermittent)]
- [Previous pain interventions (medications, procedures, therapies)]
- [Functional impact (mobility, ADLs, work)]
- [Psychosocial impact (mood, coping, sleep)]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Inspection of affected area]
- [Palpation findings]
- [Range of motion]
- [Neurological exam: motor, sensory, reflexes]
- [Other relevant systems]

Investigations:
(hyphenated list)
- [Relevant imaging or laboratory results with units]
- [Other diagnostic studies]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary pain diagnosis]

#) [Assessment as a numbered item if mentioned]
(hyphenated list with each corresponding plan item on a new line if mentioned)
- [Pain diagnosis and etiology]
- [Differential diagnosis if applicable]
- [Investigations planned or ordered]
- [Pharmacologic management (medication changes, titration, discontinuation)]
- [Non-pharmacologic management (physical therapy, psychological interventions, procedures)]
- [Patient education and counselling]
- [Referrals to other specialties]
- [Follow up plan]
- [Return precautions]