Pain Management: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Pain management documentation is among the most scrutinized in healthcare, requiring meticulous attention to regulatory compliance, risk assessment, and treatment justification. With evolving opioid prescribing guidelines, PDMP requirements, and DEA regulations, pain management SOAP notes must demonstrate clinical reasoning, document informed consent, and support the appropriateness of treatment decisions. This guide provides comprehensive instructions for documenting pain management encounters in compliance with federal and state regulations.

Unique Aspects of Pain Management Documentation

Pain management documentation differs from other specialties due to heightened regulatory scrutiny and the complexity of chronic pain care:

1. Regulatory Compliance: Must align with DEA requirements, state PDMP laws, and CDC opioid prescribing guidelines
2. Risk Stratification: Mandatory documentation of opioid risk assessment tools (ORT, SOAPP-R, DIRE)
3. PDMP Review: Required documentation of prescription drug monitoring program checks
4. Opioid Agreements: Treatment contracts and informed consent for controlled substances
5. Urine Drug Testing: Documentation of monitoring protocols and results interpretation
6. Multimodal Treatment: Evidence that non-opioid and non-pharmacologic treatments are utilized
7. Functional Assessment: Tracking functional improvement, not just pain scores
8. Medical Necessity: Clear justification for continued opioid therapy

2026 Regulatory Framework

CDC Clinical Practice Guideline for Prescribing Opioids (2022, Updated)

Per the CDC Opioid Prescribing Guideline:

1. Nonpharmacologic and nonopioid therapy are preferred for chronic pain
2. Establish treatment goals before starting opioid therapy
3. Start low, go slow: Use lowest effective dose
4. Evaluate benefits and harms within 1-4 weeks of starting opioids
5. Assess risk using validated tools before and during therapy
6. Check PDMP before prescribing and periodically during treatment
7. Use urine drug testing before starting and at least annually
8. Avoid concurrent benzodiazepine prescribing when possible
9. Offer naloxone when prescribing opioids to high-risk patients

DEA Controlled Substance Requirements

Per 21 CFR Part 1306 - DEA Prescribing Rules:

• Schedule II prescriptions require written prescription (electronic prescribing for controlled substances - EPCS - is permitted)
• No refills allowed for Schedule II medications
• Legitimate medical purpose and course of professional practice must be documented
• Prescriber must have valid DEA registration
• Patient relationship must be established

CMS 2026 Opioid-Related Requirements

Per CMS 2026 Physician Fee Schedule:

• Pain management services documentation must support medical necessity
• Prior authorization requirements for certain opioid prescriptions
• Opioid treatment program (OTP) documentation requirements

Subjective Section (S)

The Subjective section in pain management requires comprehensive pain characterization, functional impact assessment, and risk factor documentation.

Subjective Section (S) Components

1. Chief Complaint:

   • Primary pain complaint with duration
   • Treatment context (initial evaluation vs. follow-up)
   • Example: "Follow-up for chronic low back pain management, 15 years duration"

2. Comprehensive Pain Assessment (PQRST):

   • P - Provocative/Palliative: What makes pain worse or better
   • Q - Quality: Character of pain (burning, aching, sharp, stabbing, throbbing)
   • R - Region/Radiation: Location and radiation pattern
   • S - Severity: Current, best, worst, average pain scores (0-10)
   • T - Timing: Onset, duration, frequency, constant vs. intermittent
   • Example: "Constant aching low back pain, 6/10 currently (worst 9/10, best 4/10), radiating to left posterior thigh, worse with prolonged standing, improved with rest and medication"

3. Functional Impact Assessment:

   • Activities of daily living (ADLs)
   • Instrumental ADLs (work, driving, housework)
   • Sleep quality
   • Mood and relationships
   • Work/disability status
   • Example: "Pain limits standing to 15 minutes, unable to work as electrician, sleeping 4-5 hours/night with frequent awakenings"

4. Current Pain Treatment Regimen:

   • All pain medications (opioids, non-opioids, adjuvants)
   • Dosages, frequency, adherence
   • Effectiveness and side effects
   • Example: "Oxycodone 10mg q6h PRN (taking 3-4 tablets daily), gabapentin 300mg TID. Reports 50% pain relief. Mild constipation managed with docusate."

5. Treatment History:

   • Prior medications tried and outcomes
   • Interventional procedures performed
   • Physical therapy and other non-pharmacologic treatments
   • Surgical history related to pain condition
   • Example: "Failed trials of NSAIDs (GI upset), tramadol (inadequate relief). Completed 12 weeks PT with minimal improvement. L4-L5 laminectomy 2018 with temporary improvement."

6. PDMP Review Discussion:

   • Acknowledgment that PDMP was reviewed
   • Discussion of any concerns identified
   • Per state PDMP requirements
   • Example: "PDMP reviewed on [date]. Patient receiving controlled substances only from this practice. No concerning patterns identified."

7. Risk Assessment Tools:

   • Opioid Risk Tool (ORT) score
   • Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
   • DIRE Score (if applicable)
   • Example: "ORT Score: 7 (moderate risk). SOAPP-R: 12 (low risk)."

8. Substance Use History:

   • Current and past alcohol use (quantity, frequency)
   • Tobacco use
   • Illicit drug use history
   • Personal and family history of substance use disorders
   • Example: "Denies current illicit drug use. History of alcohol use disorder, in recovery x 8 years. Family history of opioid use disorder (brother)."

9. Mental Health Screening:

   • Depression screening (PHQ-2/PHQ-9)
   • Anxiety screening (GAD-2/GAD-7)
   • History of psychiatric conditions
   • Example: "PHQ-9: 8 (mild depression). Reports chronic pain has negatively impacted mood. Seeing therapist monthly."

10. Safety Assessment:

    • Suicidal ideation screening
    • Access to firearms
    • Safe medication storage
    • Example: "Denies SI/HI. Medications stored in locked cabinet away from grandchildren."

11. Medication Agreement Compliance:

    • Adherence to opioid treatment agreement
    • Early refill requests
    • Lost/stolen medication reports
    • Example: "Compliant with opioid agreement. No early refill requests. Brings pill count to each visit."

Example Subjective Section for Pain Management

Objective Section (O)

The pain management Objective section documents physical examination findings, vital signs, urine drug testing results, and observational assessments for signs of medication misuse.

Objective Section (O) Components

1. Vital Signs:

   • Blood pressure (important for pain assessment and medication effects)
   • Heart rate
   • Weight (for medication dosing and monitoring)
   • Pain score (per facility protocol)
   • Example: "BP 132/78, HR 72, Weight 195 lbs (stable), Pain 5/10"

2. General Appearance and Behavior:

   • Level of distress
   • Affect and demeanor
   • Signs of sedation or intoxication
   • Gait observation
   • Example: "Alert, well-groomed, no acute distress. Normal affect. Ambulates with antalgic gait favoring left. No signs of sedation."

3. Pain-Focused Physical Examination:

   • Inspection (posture, guarding, swelling)
   • Palpation (tenderness, muscle spasm)
   • Range of motion (with pain behavior notation)
   • Neurological examination (strength, sensation, reflexes)
   • Special tests relevant to condition
   • Example: "Lumbar spine exam: Tenderness L4-L5 paraspinals bilaterally, left > right. Positive straight leg raise left at 45 degrees. L5 dermatomal hypesthesia left."

4. Functional Assessment:

   • Observed functional capacity
   • Gait analysis
   • Ability to rise from chair, get on exam table
   • Example: "Able to walk to exam room without assistance. Uses arms to rise from chair. Can heel-walk and toe-walk with mild difficulty."

5. Signs of Misuse Evaluation:

   • Behavioral observations (appropriate vs. concerning)
   • Physical signs (pupil size, track marks, coordination)
   • Consistency between reported pain and observed behavior
   • Document using objective, non-judgmental language

6. Urine Drug Testing Results:

   • Specimen validity testing
   • Expected medications present
   • Unexpected substances (positive or negative)
   • Interpretation and action taken
   • Example: "UDT (immunoassay): Positive for oxycodone (expected), negative for benzodiazepines, THC, cocaine, amphetamines, opiates. Consistent with prescribed regimen."

7. Pill Count (if performed):

   • Number of pills remaining
   • Calculation of expected vs. actual
   • Example: "Pill count: 24 oxycodone tablets remaining. Prescribed 90 tablets on [date], 28 days ago. Expected remaining: 22-26. CONSISTENT."

8. Review of Imaging/Diagnostics:

   • Relevant imaging findings
   • EMG/nerve conduction studies
   • Laboratory results

Example Objective Section for Pain Management

Assessment Section (A)

The pain management Assessment synthesizes clinical findings, documents risk stratification, evaluates treatment response, and justifies continued therapy.

Assessment Section (A) Components

1. Pain Diagnosis:

   • Primary pain diagnosis with ICD-10 code
   • Underlying pathology
   • Chronicity (acute, subacute, chronic)

2. Opioid Therapy Assessment:

   • Indication for opioid therapy
   • Treatment response (function, pain, quality of life)
   • Tolerance assessment
   • Dependence vs. addiction assessment

3. Risk Stratification:

   • Current risk level (low, moderate, high)
   • Basis for risk assessment
   • Changes from prior assessment

4. Treatment Response Evaluation (4 A's):

   • Analgesia: Degree of pain relief
   • Activity: Functional improvement
   • Adverse effects: Side effects and management
   • Aberrant behaviors: Any concerning behaviors

5. Benefits vs. Risks Analysis:

   • Document ongoing benefit
   • Weigh against risks
   • Support for continued treatment

Example Assessment Section for Pain Management

Plan Section (P)

The pain management Plan documents multimodal treatment strategies, controlled substance prescribing details, monitoring protocols, and safety planning.

Plan Section (P) Components

1. Multimodal Treatment Plan:

   • Pharmacologic interventions (opioid and non-opioid)
   • Interventional procedures
   • Physical/occupational therapy
   • Psychological/behavioral therapies
   • Complementary approaches

2. Opioid Prescribing Details:

   • Specific medication, dose, quantity, directions
   • Rationale for dose (continuation, increase, decrease, rotation)
   • MME calculation
   • PDMP documentation statement

3. Non-Opioid Medications:

   • Adjuvant analgesics
   • Medications for side effect management
   • Tapering plans if applicable

4. Monitoring Plan:

   • UDT frequency
   • Pill count schedule
   • PDMP review frequency
   • Follow-up interval

5. Opioid Agreement Documentation:

   • Status of treatment agreement
   • Any updates or discussions

6. Safety Planning:

   • Naloxone prescription
   • Storage instructions
   • Overdose prevention education

7. Interventional Procedures:

   • Planned procedures with rationale
   • Prior authorization status

8. Referrals:

   • Specialty referrals
   • Behavioral health
   • Substance use treatment if needed

Example Plan Section for Pain Management

AI-Assisted Documentation for Pain Management

As of 2025, 66% of healthcare providers utilize AI tools in their practice. AI scribes can significantly reduce documentation burden for pain management providers while maintaining the comprehensive records required for regulatory compliance.

How AI Can Help with Pain Management Documentation

• Pain assessment capture: Documents comprehensive PQRST pain characterization from patient conversation
• Medication reconciliation: Accurately captures complex medication regimens with dosing
• Functional assessment: Documents patient-reported functional status and changes
• Compliance documentation: Assists with standardized monitoring documentation
• Template generation: Creates structured notes with required elements

Controlled Substance Documentation Considerations

Critical Elements AI Must Capture Accurately:

• Medication names and dosages: Verify exact opioid doses, quantities, and directions
• PDMP review documentation: Confirm statement that PDMP was reviewed
• UDT results: Verify interpretation accurately reflects results
• Pill count results: Confirm numbers and calculations
• Risk assessment scores: Verify ORT, SOAPP scores if discussed
• MME calculations: Double-check morphine equivalent dosing

What AI Captures Well:

• Patient-reported pain levels and descriptors
• Functional status descriptions
• Treatment history discussion
• Side effect reporting
• Patient goals and preferences
• Education and counseling provided

What Requires Careful Clinician Review:

1. Opioid prescribing details: ALWAYS verify medication, dose, quantity, directions
2. PDMP findings: Ensure documented review is accurate
3. Risk stratification: Confirm assessment aligns with clinical judgment
4. Behavioral observations: Verify observations match your assessment
5. Compliance language: Ensure agreement status accurately documented
6. MME calculations: Verify morphine equivalent doses

AI Documentation Review Checklist for Pain Management

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Pain Management Documentation

Telehealth for pain management involving controlled substances requires careful attention to both telehealth documentation requirements and DEA regulations.

DEA Telehealth Prescribing Rules for Controlled Substances

Per DEA Telehealth Prescribing Regulations and the 2024 Telemedicine Final Rule:

Current Framework (as of 2025):

1. Establishing Patient Relationship: The DEA requires at least one in-person evaluation for prescribing controlled substances, unless specific exceptions apply
2. Telemedicine Exceptions: Special registration may allow prescribing via telemedicine in certain circumstances
3. State Laws Apply: Many states have additional restrictions on telehealth prescribing of controlled substances
4. Schedule II Limitations: Most stringent requirements apply to Schedule II opioids

Documentation Requirements for Telehealth Controlled Substance Visits:

1. In-Person Relationship Documentation: Document date and nature of qualifying in-person evaluation
2. Telehealth Platform: HIPAA-compliant, audio-video required for controlled substance discussions
3. Patient Identity Verification: Robust verification required
4. State Locations: Document both patient and provider state (critical for licensure and prescribing authority)
5. Examination Limitations: Clearly document what cannot be assessed via telehealth
6. Appropriateness Statement: Justify why telehealth is appropriate for this controlled substance patient

Telehealth Pain Management Documentation Template

State-Specific Considerations

Important: State laws vary significantly regarding telehealth prescribing of controlled substances. Before prescribing:

1. Verify prescriber is licensed in patient's state
2. Confirm state allows telehealth prescribing of controlled substances
3. Document compliance with state-specific requirements
4. Some states require more frequent in-person visits
5. Some states prohibit initial controlled substance prescriptions via telehealth

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Pain Management SOAP Note Templates

Chronic Pain Follow-Up Template

Opioid Treatment Agreement Documentation Template

Related Resources

• Telehealth SOAP Notes Guide
• AI-Assisted Documentation Guide
• Psychiatry SOAP Notes
• Physical Therapy SOAP Notes
• Free SOAP Note Templates

Official Resources and References

Federal Agencies

• CDC Clinical Practice Guideline for Prescribing Opioids for Pain
• DEA Prescribing Requirements (21 CFR 1306)
• DEA Telemedicine Prescribing
• CMS 2026 Physician Fee Schedule
• SAMHSA Opioid Treatment Resources

Professional Organizations

• AMA Opioid Resources
• American Academy of Pain Medicine
• PDMP TTAC (Training and Technical Assistance Center)