PAIN-DOCUMENTATION

SUMMARY

DEMOGRAPHICS
1. Age, sex

DIAGNOSIS
2. Clinical diagnosis: both medical and psychiatric/psychological issues

BACKGROUND
3. Background medical issues
4. Medication history: including analgesics, medicinal cannibis

CURRENT SYMPTOMS
5. Pain characteristics & severity
6. Stimulus-dependent or stimulus-independent pain
7. Other associated pain-related findings such as allodynia and sensitisation? Mechanical (dynamic, punctate, and static) vs. thermal (cold and heat) stimuli?

FUNCTION, DISABILITY & HEALTH
8. Self-maintenance: whether the patient is able to take care of self or requires assistance?
9. Rest: how many hours is the patient able to sleep, is it good quality?
10. Leisure: able to do social activities or hobbies?
11. Productivity: is the patient able to work?

CONTEXT
12. Social issues?
13. Psychology: thoughts and strategies regarding pain management?

Reference(s)

Cifu, D.X. (2020). Braddom’s physical medicine and rehabilitation. Elsevier. Get it on Amazon.
Cuccurullo, S. (2019). Physical medicine and rehabilitation board review. New York: Demosmedical. Get it on Amazon.
O’Young, B., Young, M.A. and Stiens, S.A. (2008). Physical Medicine and Rehabilitation Secrets. Mosby. Get it on Amazon.