1. Add the template
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Template content
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Chronic Pain Visit Pain History - Onset, location(s), radiation, quality, timing, severity (scores if used), and aggravating/alleviating factors. - Prior workup, procedures, surgeries, and responses to treatments tried. - Red flags: progressive neurologic deficit, bowel/bladder change, unexplained weight loss, fever, history of cancer, IVDU as relevant. Function, Mood & Sleep - ADLs, work/disability status, walking/sitting tolerance, sleep, mood, substance use, and social supports. - Patient-defined functional goals. Medications & Non-Drug Therapies - Current and prior analgesics, adjuvants, opioids (morphine milligram equivalents context if calculated locally), and side effects. - PT, exercise, CBT/pain psychology, injections, devices, complementary therapies. Risk Assessment (if opioids or controlled substances involved) - PDMP, UDS, aberrant behaviors, agreement status, overdose history, naloxone, and psychiatric comorbidity screening as performed. Exam - Focused MSK/neuro exam; gait; relevant joint/spine findings; pertinent negatives. Assessment - Chronic pain diagnoses/syndromes and contributing biopsychosocial factors. - Benefit/risk of current controlled medications; appropriateness of continuation vs taper vs non-opioid focus. Plan - Multimodal plan with medication changes, referrals, activity progression, and behavioral supports. - Monitoring, refill cadence, and follow-up interval. - Education and shared decision-making documented.
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
- Elevates function, mood, sleep, and goals alongside pain intensity.
- Supports opioid and non-opioid pathways with explicit risk documentation.
- Encourages multimodal planning (PT, behavioral, procedures, meds).
- Works as a fuller cousin to shorter pain-management follow-up notes.
- 1New or comprehensive chronic pain evaluations
- 2Periodic chronic pain reassessment visits
- 3Primary-care or pain-clinic multimodal planning
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.
Pain History 58-year-old with 4 years of axial low-back and bilateral buttock pain after lifting injury; MRI with degenerative disc disease L4–S1, no surgical lesion per ortho 2024. Average pain 5/10; flares to 8/10. No red-flag neurologic symptoms. Function / Mood Works modified duty warehouse; sits poorly >30 min. Sleep fragmented. PHQ-9 = 6. Goal: walk 30 minutes and return to full duty. Therapies Tried PT with partial benefit; home exercises inconsistent. Duloxetine 60 mg helpful for pain and mood. Occasional ibuprofen. No opioids currently; historically oxycodone PRN stopped 2023 without withdrawal issues. Exam Limited lumbar flexion; negative SLR; strength 5/5; no myelopathic signs. Assessment Chronic mechanical low-back pain with myofascial component; mood/sleep contributors. Non-opioid multimodal plan appropriate. Plan Restart PT focus on core/hip; duloxetine continued; topical diclofenac; sleep hygiene; pain psychology referral offered—patient will consider. Avoid opioids. Follow up 8 weeks; sooner for progressive weakness or bowel/bladder change.
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
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Put this template to work on your next visit
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