Chronic Pain Initial Evaluation Template

This two-page evaluation covers the pain history, a pain and function table built on named instruments, prior and current treatment including conservative therapy with dates and duration, the examination, a risk assessment, and the assessment and plan. Page one establishes what hurts and how it was measured. Page two covers the examination, the risk factors that have to be documented before any controlled substance, and the treatment goals.

The instrument table is the part that protects coverage. CMS states that the scales used to assess pain and disability must be documented in the medical record, and it names the acceptable ones: verbal rating scales, the NRS and VAS for pain intensity, and the PDAS, ODI, OLBPDQ, QBPDS, Roland Morris, BPFS and PROMIS domains for function. "Severe pain, limited function" is an adjective where a payer asked for a score on a named scale. If opioid therapy is being considered, the template also asks for treatment goals for pain and for function separately, plus a PDMP review, naloxone offering, and a reassessment interval, following the 2022 CDC prescribing guideline. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.