Chronic Pain Management Clinic Evaluation(compose as a narrative with complete sentences, first person, may refer to patient by their first name.)
[Patient Name seen in evaluation on date of transcription, referred by referring physician and when for reason for chief complaint.] (always include as will be mentioned either in transcript, contextual notes or clinical note.) [Duration of Evaluation](always include, this can be found in the transcript, contextual notes or clinical note.)
[Describe current issue(s), reasons for visit, discussion topics, history of presenting complaints, etc. Describe pain specifically including qualitative characteristics, where it anatomically located, quality, when it is worse, exacerbating factors, relieving factors, and score out of 10. Impacts on daily functioning should be noted, including mobility, sleep, mood, working, social relationships.] (note that there may be multiple issues, describe each one in detail) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe pain interference score total score, what two individual components of the score were most severe, and specific symptoms that were highlighted on the pain interference questionnaire.](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe a summary of the outcome of past interventions and how these affected the symptoms.](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Nonpharmacologic Management
[Describe past physiotherapy, occupational therapy, counselling, psychology, psychiatry, chiropractor, athletic therapy, etc. and how this affected the symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise state "no nonpharmacologic management has been tried".)
Pharmacologic Management
[Describe medication(s) the patient is currently taking to treat pain e.g. narcotics, NSAIDs, acetaminophen, gabapentin, pregabalin, antidepressants, topical treatments; including the dose, frequency and how long they have been on the medication(s). and how this affected the symptoms. Also include past medication(s) trialed, how they worked and the reason for stopping, how long they were on it, and when they stopped.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise state "no pharmacologic management has been tried".)
Interventional Management
[Describe past surgeries or pain interventions including blocks, steroid injections, radiofrequency ablation, etc. who did them, how many times and how this affected the symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise state "no interventional management has been tried".)
Past Medical History
[Describe past medical history, excluding previous surgeries] (write as a numbered list, only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise write "no significant past medical history".)
Past Surgical History
[Describe previous surgeries] (write as a numbered list, only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise write "no previous surgeries".)
Allergies
[Mention allergies and reaction if known] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medications
[Describe medications, do not include dose or frequency](write as a numbered list, only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise write "no regular medications".)
Social History
[Describe social history including where the patient lives, occupation, alcohol consumption, smoking status, any other recreational medication use, etc.](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Physical Examination(write as narrative)
[Describe general appearance, if they were calm, anxious or in distress and vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe pain behaviours including guarding, holding affected limb a certain way, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe specific findings related to the affected area(s) including size, colour, temperature and skin characteristics, how the it is compared to the contralateral side, presence of scars, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe gait, was it antalgic, steppage, etc., ability to walk on heels and toes, etc.](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe range of motion of affected extremities, back or neck as either full, compared to contralateral extremity or in degrees](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe neurological examination findings including reflexes, clonus, Babinski relfex, etc.](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe strength graded out of 5 and both sides if applicable.](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe sensation to light tough and/or pinprick either as normal, intact or graded out of 10, include allodynia, hyperalgesia, withdrawal from stimulus, cold sensation, location(s) of Tinel's sign, etc.](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe palpation findings related to the affected area(s) including tenderness, masses, contractures, how the it is compared to the contralateral side, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Investigations(as numbered list)
[Describe as a summary prior electrodiagnostic findings including nerve conduction studies and EMG, when they were done and by who] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe as a summary prior imaging findings including x-ray, MRI, bone scan, CT, ultrasound, when they were done] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Diagnostic Code(s):
[most likely diagnostic code as ICD-10] (generate most likely ICD-10 code, if none can be found leave blank.)
Impression and Plan(write as narrative, first person.)
[Summarize the patient's condition and diagnostic impression] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Describe the discussed diagnostic and therapeutic interventions, including their benefits, risks, and alternatives] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Mention any additional investigations or referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Include any patient education or counselling provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
All questions were answered.
[Follow-up: describe when, where and for what i.e. intervention or reassessment] (always include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
It is a pleasure to be involved in the care of this patient.
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)