Box 3.5 Documentation charting sheet for post-treatment assessment for
chronic pain
Post-treatment evaluation
Patient name: _________________ Date:____________
Goal attainment (include specific targets achieved):
® Improve function
❑
❑
❑
❑
❑
Household chores
Yard work
Leisure activities
School attendance
Work
® Improve ability to participate in rehabilitation
® Provide safe, tolerated treatment
® Reduce pain to moderate severity level
Compliance with prescribed therapy: YES
Tolerability:
❑
❑
❑
❑
❑
❑
❑
NO
Regular bowel movements (record frequency): ___________
Sedation/cognitive effects
Weight change: ___________
Dry mouth
Dizziness
Nausea
Other: ___________
Treatment recommendations:
❑ Continue current treatment
❑ Change in therapy: ____________
Follow-up scheduled in ___weeks/months
Provider signature and date: _____________
I certify that my doctor and/or his team explained my diagnosis, treatment
recommendations, and the expected benefits and risks from treatment. I am
satisfied that my questions were answered and will comply with my treatment
recommendations and follow-up. __________________________
(Patient signature and date)
D. Marcus, Chronic Pain: A Primary Care Guide to Practical Management,
© Humana Press, a part of Springer Science + Business Media, LLC 2009
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