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Template content
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Pain Management Follow-Up Visit Context - Pain diagnoses under treatment and interval since last visit. - Patient goals for today’s visit (function, sleep, medication adjustment). Pain & Function Interval History - Location, character, average/worst/best pain scores if used, and temporal pattern. - Functional status: ADLs, work, walking tolerance, sleep, mood impact. - Flare triggers and response to current plan; new neurologic or red-flag symptoms. Current Regimen & Adherence - Pharmacologic therapies with doses; non-opioid and adjuvant meds. - Non-pharmacologic therapies (PT, home exercise, CBT, acupuncture, injections) and adherence. - Side effects, diversion/misuse concerns as discussed. Risk & Monitoring (as applicable) - PDMP review, urine drug screen results, pill counts, controlled-substance agreement status. - Depression/suicide risk screening context if performed; naloxone status. Exam - Focused musculoskeletal/neuro exam pertinent to pain generators; pertinent negatives. Assessment - Pain syndrome status (improved / stable / worse) and contributing factors. - Benefit vs risk of current controlled medications if prescribed. Plan - Medication changes with rationale; taper plans if indicated. - Referrals, procedures, PT progression, and behavioral supports. - Monitoring interval, refill plan, and return precautions for red flags.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Balances pain intensity with function and goal progress.
- Keeps opioid/risk review (PDMP, UDS, agreements) in a consistent place when applicable.
- Supports multimodal plans: PT, procedures, behavioral strategies, and meds.
- Works for primary-care pain follow-ups and specialty pain clinic returns.
- 1Chronic pain medication follow-up visits
- 2Multimodal pain regimen reviews
- 3Primary-care managed pain with periodic reassessment
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Context Follow-up for chronic lumbar radicular pain post L4–5 disc herniation (non-operative). Interval 6 weeks. Interval / Function Average pain 4/10 (was 6/10); worst 7/10 with prolonged sitting. Walking 20 minutes tolerated. Sleep improved. No bowel/bladder change, saddle anesthesia, or progressive weakness. Regimen Gabapentin 300 mg TID (adherent); naproxen PRN; home McKenzie exercises most days. Declined opioid therapy previously. PT ×8 sessions completed. Risk Not on controlled substances; PDMP N/A. PHQ-2 negative today. Exam Steady gait; positive seated slump on right mildly improved; strength 5/5; sensation intact. Assessment / Plan Improving chronic right L5 radicular pain. Continue gabapentin; discuss slow wean in 4–6 weeks if gains hold. Advance PT home program; ergonomic counseling for desk work. MRI not repeated—prior imaging 3 months ago unchanged clinically. Return 6 weeks or sooner for progressive weakness, saddle anesthesia, or intractable pain.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Put this template to work on your next visit
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