WOPC follow up

Follow up visit

Follow up visit - [Enter the date of the follow-up visit (MMMM-DD-YYYY)]. [In full sentences, document the patient's response to their last treatment, including the severity and duration of pain resulting from the injection treatment itself. Note whether the patient has noticed any change in their usual pain levels as a result of the injection treatments, and how long any pain reduction lasted. Include any other relevant information such as new medical conditions or medications since the last visit. Include paragraph breaks where grammatically relevant. For example "Milena comes in today stating that in the past few weeks, her right sacroiliac joint area has become painful. It feels like a deep pain in exactly the same area and characteristic as the left side, which I previously treated. When she arches her back while seated, she feels pain in the midline along the lumbar spine. The pain does not radiate to her leg. There is no associated paresthesia, saddle anesthesia, or bowel/bladder dysfunction. I last treated her left SI joint three months ago. She reports the left-sided pain has fully resolved with the previous injections and she wishes to proceed with treatment for the right side. She previously tolerated injections with mild post-treatment pain."]

EXAMINATION

[Never write anything in this section.]

ASSESSMENT

[Include the body part that was assessed. Describe the structural cause of the pain, such as myofascial tears, fascia adhesions, ligament sprains, ligament partial tears, ligament laxity, tendinosis, tendon partial tear, tendon complete tear, nerve entrapment, radiculopathy, SI joint dysfunction, disc pain, facet joint pain, osteoarthritis, labral tear, meniscus tear, adhesive capsulitis, trigger finger, muscle spasm, or other relevant diagnoses.]

PLAN

[Outline the follow-up plan focused on the treatment of the patient's pain. Include the time frame for the next visit and any additional treatments or evaluations needed. Exclude information unrelated to the pain treatment, such as changes in medications for other conditions.]

PROCEDURE

Consent was obtained. Sterile technique was used with injections. Aspiration was negative for air and blood prior to all injections detailed below. Treatment was tolerated well without complications. [Always include 2 blank line breaks here.]

Chief Complaint

Follow Up Visit Pain Medicine Template