Telehealth Pain Medicine Follow up Visit

OVERALL_INSTRUCTIONS

Chief Complaint

[chronic|subacute|acute] [right|left|midline|bilateral|axial|null] [neck|shoulder|arm|low back|buttock|leg|foot|hip|null] pain

Template

Date of Consultation: [date] Mode: [Audio/ Video call] TELEHEALTH CONSENT: ☐ Patient verbally consented to telehealth consultation ☐ Patient identity verified via [method] (Note: Use language that accurately reflects and explicitly acknowledges the virtual nature of the encounter. The note should maintain medical accuracy and professionalism while clearly indicating assessments were conducted remotely. Avoid phrases that imply direct physical examination or patient's physical presence. Clearly differentiate between: - Provider's observations via video - Patient's self-reported symptoms - Patient's self-conducted physical assessments - Information from home monitoring devices - Previously documented findings referenced during the visit) This [age][gender] was reviewed today via Telehealth for follow-up of [chronic|subacute|acute] [right|left|midline|bilateral|axial|null] [neck|shoulder|arm|low back|buttock|leg|foot|hip|null] pain. INTERVAL HISTORY: (include only the items that were discussed) Progress since last visit: [improved|worsened|stable] Current pain symptoms: [summary of location, quality, severity] Mean daily pain: [1–10]/10; Max daily pain: [1–10]/10 Associated symptoms: [none|bowel/bladder issues|gait difficulties|null] Functional status: [unchanged|improved|declined]; walking [unassisted|with cane|walker|wheelchair] Sleep: [no|mild|moderate|severe] impact Mood: [good|mildly depressed|anxious|frustrated] New medical events since last visit: [none|list briefly] INVESTIGATIONS REVIEWED: [List labs/imaging reviewed and findings] [Any pending results noted] CURRENT MEDICATIONS: [List active pain medications and dosages, or "None"] ADHERENCE TO PREVIOUS PLAN: [Adherent|Partially adherent|Non-adherent] to physical therapy, medications, or other interventions PHYSICAL EXAM: [Document any relevant findings or state "not performed due to virtual nature of visit"] IMPRESSION: [List updated problem list, one per line] PLAN: [Adjustments to medications, if any] [Further investigations if required] [Referral to multidisciplinary services if needed] [Patient education provided: e.g., importance of exercise, pacing strategies, psychological supports] [Next steps for pain interventions if indicated] FOLLOW-UP PLAN: Next follow-up via Telehealth or in-person in [timeframe] Patient advised to contact clinic if symptoms worsen or new neurological symptoms develop