Free Printable Back Pain Soap Note Template
Printable Back Pain Soap Note
Prepared by: [Your Name]
I. Subjective
A. Chief Complaint
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The patient reports persistent lower back pain for the past two weeks.
B. History of Present Illness (HPI)
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The pain started after lifting a heavy object at work.
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Described as a dull ache, occasionally sharp when bending or twisting.
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Pain level: 6/10 on a numeric pain scale.
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Worse with prolonged sitting or standing; improved with rest and heat application.
C. Past Medical History
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History of mild sciatica 3 years ago.
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No prior surgeries or major trauma.
D. Medications
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Currently taking over-the-counter ibuprofen (400 mg twice daily).
E. Additional Notes
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Denies numbness, tingling, or weakness in the legs.
II. Objective
A. Physical Examination Findings
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Inspection: No visible deformity or swelling in the lumbar region.
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Palpation: Tenderness over the L4-L5 region; no muscle spasms noted.
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Range of Motion: Limited forward flexion; extension and lateral movements are mildly painful.
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Neurological Exam: Normal reflexes, muscle strength, and sensation in lower extremities.
B. Diagnostic Tests
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None were conducted during this visit.
III. Assessment
A. Diagnosis
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Mechanical lower back pain, likely due to muscle strain.
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Rule out disc herniation or other underlying conditions.
IV. Plan
A. Treatment Recommendations
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Continue ibuprofen as needed for pain relief, up to 3 times daily.
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Apply a heating pad for 20 minutes, 2-3 times per day.
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Avoid heavy lifting and strenuous activities for the next 1-2 weeks.
B. Therapeutic Interventions
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Refer to physical therapy for strengthening exercises and posture correction.
C. Follow-Up
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Reassess in two weeks or sooner if symptoms worsen.
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Consider imaging (X-ray or MRI) if no improvement after four weeks.
