Lower Back Pain Soap Note Examples


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Lower Back Pain Soap Note Example 1


CC: lower back pain x 1 week

HPI: 42-year-old obese female presents with complaints of lower back pain for the past week that feels worse today. The pain is constant and intermittently radiates down her left leg. It is not improved with ibuprofen. She works as a grocery store clerk.

Review of systems:

General: No fever, chills, weight changes, sweating, or general weakness.

Eyes: No blurred or double vision or pain or redness.

Ears: No pain or decrease in hearing.

Nose: No runny nose or blockage or bleeding.

Throat: No sore throat.

Head: No headache.

Chest: No chest pain or cough or shortness of breath or wheezing.

Breasts: No pain or tenderness or noticeable lump.

Heart: No irregular heart beat or palpitations or chest pain.

Gastrointestinal: No nausea or vomiting or constipation or difficulty swallowing or rectal bleeding or bloating or distension or hemorrhoids or diarrhea or abdominal discomfort.

Genitourinary: No vaginal discharge or bleeding or dysuria or vaginal problems.

Musculoskeletal: No muscle problems or weakness. Lower back pain that radiates down left leg.

Skin: No rashes or bruises or skin masses or other skin complaints.

Neurologic: No weakness or headache or seizures or numbness or tingling.

Psychiatric: No anxiety or depression or suicidal/homicidal thoughts.

Endocrine: No excessive thirst or excessive urination or excessive heat or cold.

Immunologic: No tuberculosis or hepatitis or HIV or recurrent infections.

Hematologic: No anemia or easy bruising or bleeding.

PMHx: none

FamilyHx: none

SocialHx: Pt works as a grocery store clerk

Allergies: NKA


66 in

275 lb


122/75 mmHg

78 bpm

14 bpm

97.6 °F

99 %

General: Normotensive, in no acute distress.

Head: Normocephalic, no lesions.

Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal.

Ears: EAC’s clear, TM’s normal.

Nose: Mucosa normal, no obstruction.

Throat: Clear, no exudates, no lesions.

Neck: Supple, no masses, no thyromegaly, no bruits.

Chest: Lungs clear, no rales, no rhonchi, no wheezes.

Heart: RR, no murmurs, no rubs, no gallops.

Abdomen: Soft, no tenderness, no masses, BS normal.

Back: Normal curvature, no tenderness.

Extremities: FROM, no deformities, no edema, no erythema.

Neuro: Physiological, no localizing findings.

Skin: Normal, no rashes, no lesions noted.

Lower Back Pain Soap Note Examples.


Actual Dx:

  • (E66.0) Obesity, body mass index (bmi 40-44.9).
  • (M54.5) Dorsalgia, acute low back pain.

ICD-10-CM Codes. (2019). Retrieved from https://www.icd10data.com/ICD10CM/Codes/


– begin medications listed below as needed.

– pt educated on the importance of weight loss and dietary modification to reduce back strain

– RTC for follow up in 30 days if symptoms persist

  • Ultram (tramadol) 100 MG Oral Tablet Sig: Take 1 tablet (100 mg) by mouth every 6 hours as needed for pain. #40, no refills.
  • Flexeril (cyclobenzaprine) 10 MG Oral Tablet Sig: Take 1 tablet (10 mg) by mouth every 8 hours as needed. Take at bedtime if drowsiness occurs. #30, no refills.

Ultram, Flexeril: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (2019). Retrieved from https://www.webmd.com/drugs

Lower Back Pain Soap Note Examples.


Provide education to pt on the importance of dietary modification and exercise in order to lose weight and reduce strain on her back. Stress the importance of establishing goals and the health benefits associated with a healthy BMI. If necessary and pt continues to struggle in 30 days will refer to dietician for additional support on nutrition and increasing her level of physical activity (UpToDate, 2019).

Lower Back Pain Soap Note Example 2

History & Physical Examination

Patient Demographics:

Name: T.H.

Age/race/sex: 26 Hispanic Female

Clinical site: Primary Care clinic; Presents for sick visit.

Lower Back Pain Soap Note Examples.


Chief Complaints:  “My lower back has been hurting for about 2 weeks now”.

History of Present Illness:  

Mrs. H is a 26 y/o Hispanic female with a six year history of depression-controlled on Sertraline, who presents to the clinic today complaining of spontaneous occurring acute low back pain to lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has been very difficult to dress lower body and to bend. She reports the pain is constant but has intermittent intensities of aching and soreness throughout the day.

The pain is localized to the lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today with 3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has experienced. Reports the pain is worse in the mornings when getting out of bed after lying down all night. She hasn’t tried any pharmacological or non-pharmacological therapies.

She reports no heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped head first over the handle bars of the bike. At which time she experienced this same low back pain, went to the ER and had X-rays that showed some inflammation and swelling. She was then prescribed a muscle relaxant, Ibuprofen, and physical therapy for 8 weeks, which helped tremendously. At today’s visit, she hopes to find out where the pain is coming from and what she can do to prevent it from returning.

Lower Back Pain Soap Note Examples.

Past Medical History:

  • Depression-active- diagnosed 6 years ago after mom passed in a MVA
  • Low back pain-active-diagnosed about 5 years ago after previous back injury.

Past Surgical History:

  • No surgeries to date


NKA to food, dust, mold, environment, or medications.


Sertraline 150 mg by mouth daily for depression

Health Maintenance:

  • Influenza Vaccine-October 2017 at CVS.
  • All other immunizations are up-to-date including TDaP, MMR, and Varicella.
  • Last Pap smear- June 2016-normal
  • Performs MSBE
  • Depression screen positive for PHQ2; on meds and see Psychologists regularly.
  • CAGE 0/4

 Personal & Social History:

  • Lives alone in a one-bedroom apartment.
  • Works at a nursing home as a Certified Nursing Assistant 4 days/week. She loves her job and has a dependable car.
  • Denies any smoking, illicit drug abuse, or alcohol misuse.
  • Previously did cross fit in high school. However, do to work she hasn’t had much time to get the amount of exercise she needs.
  • Patient is sexually active with only one sex partner, her boyfriend.
  • 24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich, chips, and a diet coke; S-about 1-2 cups of cheese-it crackers and a diet coke; D- Meatloaf, veggies, mashed potatoes from Boston Market, and a bottled water. Lower back pain soap note examples

Family History:


Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76 history of DM

and MI.

Maternal: Maternal grandfather died at 82 from MI, maternal grandmother 79, history

of diabetes and arthritis.


Father: Father 59, history of HTN, Diabetes, Depression, and Stroke.

Mother: Mother 52, died in a MVA.


Siblings: Only child.


Children: No children.

Lower Back Pain Soap Note Examples.

Review of Systems:  

General Denies any fever, chills, night sweats, weight loss or weight gain in the past year.
Skin Denies dry skin and itching. Denies abnormal lesions or new nevi/moles
Head Previous head injury, denies any masses, lesions and headache
Eyes Denies any discharge, itchy, blurred vision, vision loss or vision changes, eye pain or injection.
Ears Denies any itching, fullness, vertigo, ear pain or drainage, hearing loss or changes in quality of hearing.
Nose/Sinuses Denies epistaxis, PND, maxillary or frontal sinus pain, or changes in smell
Mouth/Throat Denies sore throat and dysphagia. Denies gum disease, has all original teeth, last dental exam was in July of this year, sees the dentist annually.
Neck/Lymph Nodes Denies swollen /painful lymph nodes, denies any neck pain or stiffness. Lower back pain soap note examples
Breasts Denies masses, pain, or nipple discharge. Does perform regular SBE.
Thorax/Respiratory Denies any SOB, DOE, or wheezing.
CVS Denies CP, palpitations, denies peripheral edema, Orthopnea
GI/Abdomen Denies dyspepsia, nausea, vomiting, diarrhea, constipation, bloating, hematemesis, hematochezia, or abdominal pain. No recent changes in bowel habits. Last bowel movement was this morning, which is consistent with her regular bowel habits and was normal.
GU Denies any pain on urination, frequency, urgency, or vaginal discharge.
Musculoskeletal See HPI.
Neurologic Denies memory loss, numbness, tingling, or burning pains or weakness.
Endocrine Denies known glucose abnormalities, heat or cold intolerance
Psychiatric Reports a history of depression but denies any anxiety.


Physical Examination:

Vital Signs/HT/WT T: 98.2F, P: 72 readily palpable, RR: 16, BP 110/64 on right, 110/68 on the left SaO2 on RA: 100% HT: 5’8”, WT: 128lbs (toned-physique, stable with no gains or losses within the last 6 months), BMI: 19.46, normal for ht. and wt.
General 26 y/o Hispanic female, pleasant appears her stated age sitting on the examination table in moderate distress as evidenced by arms tensed on elbows as she’s guarding pain. Well groomed, well developed, AAOx3
Skin Warm, moist, no rashes or suspicious moles, +turgor
Head/Scalp ATNC, thick black hair, no dandruff, no lesions/masses.
Eyes External examination without ptosis, strabismus or exophthalmos. Conjunctiva pink. Rest of exam deferred.
Ears Auricles symmetrical, no lesions or tophi; Rest of exam deferred.
Nose Bilateral nasal turbinates’ pink, moist. Rest of exam deferred.
Sinuses Deferred
Mouth Lips pink, moist mucous membrane, tongue protrudes in midline.
Pharynx/Throat Deferred. Lower back pain soap note examples
Neck/Lymph nodes Trachea midline with full AROM without pain.
CVS RRR, normal S1, S2, no murmurs, rubs, or extra systole, JVD 3cm at 30 degrees, no carotid bruits, no cyanosis or vascular lesions. No chest wall deformity. PMI at 5th ICM MCL. Non-tender without heaves or thrill. Auscultation of the abdomen without bruit. Palpation without pulsatile masses
Lungs/Thorax Chest symmetrical without deformity, respirations even and unlabored throughout anterior and posterior lung fields. Palpation without tenderness.  Tactile fremitus present. Resonance heard on percussion throughout anterior and posterior lung fields. Vesicular breath sounds auscultated throughout anterior and posterior peripheral lung fields.
Breasts Deferred
Abdomen Deferred
GU Deferred
Musculoskeletal Mandible moves in midline TMJ palpation without clicks or tenderness. Neck and cervical spine have no noted deformities or signs of inflammation. Curvature of cervical, thoracic and lumbar spine within normal limits. Bony features of shoulders and hips are of equal height bilaterally and non-tender. Posture is slumped and gait is smooth but guarded. Palpation of spinous processes of C7-L5 are palpable, midline, and tender to deep palpation right below L5. Discomfort noted with lying flat on exam table. Patient can bend to touch toes but experiences discomfort at about 90 degrees from the upright position. Although patient can actively perform such maneuvers as bending her knees to her chest while lying flat, flex, extend, and rotate the spine there is some mild discomfort and pain noted throughout the maneuvers.
Extremities/Pulses No edema, erythema or cyanosis to upper or lower extremities. Pulses 2/4 to bilateral femoral, popliteal, posterior tibial, and dorsalis pedis pulses.
Neurologic AA O X3. Slumped posture while sitting and walking. Gait steady and intact. Sensation intact to light, deep, and sharp touch. gait and balance intact. CN II- XII intact.  Memory and cognition intact for present and past medical history.
Psych Appropriate mood and affect
Lower Back Pain Soap Note Examples.

Evidence Based Assessment/Plan

Clinical Decision Making:  26 y/o Hispanic female presents to the primary care clinic with a two week history of constant low back pain worse when ambulating and dressing. The pain is non-radiating and has intermittent intensities of aching and soreness consistent with acute non-specific low back pain. She has experienced these symptoms before after a biking accident 5 years ago. Given Mrs. H’s presenting signs and symptoms there is a need to differentiate between the diagnosis of acute non-specific low back pain and low back pain with radiculopathy. Mrs. H is an otherwise healthy young female with a history of depression controlled on antidepressant. She has no other co-morbidities or health issues.

Differential Diagnosis:

Non-specific Acute Low Back Pain

Nonspecific or nonradicular low back pain is not associated with neurologic symptoms or signs. In general, the pain is localized to the spine or paraspinal regions (or both) and does not radiate into the leg. In general, nonspecific low back pain is not associated with spinal nerve root compression. Nonspecific low back pain might or might not be associated with significant pathology on magnetic resonance imaging (MRI) and is often a result of simple soft tissue disorders such as strain, but it can also be caused by serious medical disorders arising in the bony spine, parameningeal, or retroperitoneal regions.


Risk factors:

Smoking, obesity, older age, female gender, physically strenuous work, sedentary work, a stressful job, job dissatisfaction and psychological factors such as anxiety or depression.



Diagnosis is based on physical exam findings. Routine spine radiographs are of limited value because they visualize only bony structures. Guidelines from the U.S. Agency for Health Care Policy and Research (AHCPR) indicated value of routine spine radiographs for acute low back pain in the following settings: acute major trauma, minor trauma associated with risk of osteoporosis, risk of spinal infection, pain that does not respond to rest or recumbency, and history of cancer, fever, or unexplained weight loss. They may also be of value in assessing spinal alignment and rheumatologic disorders of bone. The American Academy of Neurology guideline recommends nonsurgical therapy before CT and MRI are used in patients with uncomplicated acute low back pain of less than 7 weeks’ duration.



Pain areas: in the low back, muscles and bones, hip, or leg.


Sensory: leg numbness or pins and needles.


Back joint dysfunction or muscle spasms.


Slumped gait due to pain on standing upright.









Some physical exam findings of low back pain may include the following;


Superficial tenderness over the lumbar region to light touch


Nonanatomic tenderness


Exacerbation of pain by applying a few pounds of pressure with the hands to the top of the head


Exacerbation of pain by simulated rotation or flexion of the spine


Ability to sit up straight from a supine position, but intolerance of the straight-leg-raising test


Nonanatomic distribution of sensory changes




Acute lumbosacral radiculopathy

Low back pain accompanied by spinal nerve root damage is usually associated with neurologic signs or symptoms and is described as radiculopathy. There is usually pathologic evidence of spinal nerve root compression by disk or arthritic spur, but other intraspinal pathologies may be present and are often apparent on an MRI scan of the lumbosacral spine.

Risk factors:

Traumatic injury

Lumbar sprain or strain

Postural strain

sitting, standing or walking >2hrs per day

frequent moving or lifting >25 lbs.

strength <50%



poor health

prior LBP

poor back endurance


Rheumatoid Arthritis



After the initial examination, the diagnosis of lumbar radiculopathy can be supported by electrodiagnosis, MRI, CT scans, and/or contrast myelography. Treatment of lumbar radiculopathy will vary depending on the actual cause of the radiculopathy. These treatments can include the use of back supports, medication, physical therapy, steroid injection in the spine, and even surgery.



Radiculopathy — A common feature of low back pain is radiculopathy, which occurs when a nerve root is irritated by a protruding disc or arthritis of the spine. Radiculopathies usually cause radiating pain, numbness, tingling, or muscle weakness in the specific areas related to the affected nerve root, usually the lower leg. Most people with these conditions improve with limited or no treatment, described below.

Lower back pain soap note examples

Sciatica — Sciatica refers to the most common symptom of radiculopathy. It is a pain that occurs when one of the five spinal nerve roots, which are branches of the sciatic nerve, is irritated, causing a sharp or burning pain that extends down the back or side of the thigh, usually to the foot or ankle. You may also feel numbness or tingling. Occasionally, the sciatica may also be associated with muscle weakness in the leg or the foot. If a disc is herniated, sciatic pain often increases with coughing, sneezing, or bearing down.

Neurogenic claudication — Neurogenic claudication is a type of pain that can occur when the spinal cord is compressed due to narrowing of the spinal canal from arthritis or other causes. The pain runs down the back to the buttocks, thighs, and lower legs, often involving both sides of the body. This may cause limping and weakness in the legs. Pain usually gets worse when extending the lower spine (e.g., when standing or walking), and gets better when flexing the spine by sitting, stooping, or leaning forward.


The onset of symptoms in patients with lumbosacral radiculopathy is often sudden and includes LBP. Some patients state the preexisting back pain disappears when the leg pain begins.

Sitting, coughing, or sneezing may exacerbate the pain, which travels from the buttock down to the posterior or posterolateral leg to the ankle or foot.

Radiculopathy in roots L1-L3 refers pain to the anterior aspect of the thigh and typically does not radiate below the knee, but these levels are affected in only 5% of all disc herniations.

When obtaining a patient’s history, be alert for any red flags (i.e., indicators of medical conditions that usually do not resolve on their own without management). Such red flags may imply a more complicated condition that requires further workup (e.g., tumor, infection). The presence of fever, weight loss, or chills requires a thorough evaluation. Patient age is also a factor when looking for other possible causes of the patient’s symptoms. Individuals younger than 20 years and those older than 50 years are at increased risk for more malignant causes of pain (e.g., tumor, infection).


Lower Back Pain Soap Note Examples
Patient SOAP Note Charting Procedures


  • American Academy of Family Physicians. (2017). Diagnosis and Treatment of Low Back Pain; Clinical Practice Guidelines. Retrieved from: http://www.aafp.org/patient-care/clinical-recommendations/all/back-pain.html
  • American Association of Neuromuscular & Electrodiagnostic Medicine. (2017). Lumbar Radiculopathy. Retrieved from: http:www.aanem.org/Patients/Disorders/Lumbar-Radiculopathy
  • Cleveland Clinic Center for Center for Continuing Education. Published by; Levin, Kerry. M.D. (2010). Low Back Pain. Retrieved from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/low-back-pain/#top
  • Healthline. (2017). Radiculopathy (Pinched Nerve). Retrieved from: https://www.healthline.com/health/radiculopathy#overview1 Lower back pain soap note examples
  • Scientific Electronic Library Online by Ladeira, Carlos (2011). Evidence based practice guidelines for management of low back pain: physical therapy implications. Retrieved from: http://www.scielo.br/pdf/rbfis/v15n3/04.pdf
  • U.S. Preventive Services Task Force. (2017). Grade A and B Recommendations. https://www.uspreventiveservicestaskforce.org/Search
  • UpToDate. (2017). Patient Education. Low Back Pain in Adults (Beyond the Basics). Retrieved from: https://www.uptodate.com/contents/low-back-pain-in-adults-beyond-the-basics Lower back pain soap note examples

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Lower Back Pain Soap Note Examples
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Frequently Asked Questions (FAQs)

1. How do you describe lower back pain?

Pain that is dull and agonizing

Axis pain is described as dull and aching rather than searing, stinging, or acute pain that persists in the low back. Mild to severe muscular spasms, limited movement, and soreness in the hips and pelvis can accompany this type of discomfort.

2. How do you describe back pain in words?

  • Sharp.
  • shooting.
  • Dull, aching.
  • Stabbing.
  • Throbbing.

3. What should be included in a SOAP note assessment?

  • The patient’s description
  • The precise interventions in detail.
  • The tools employed.
  • Changes in the patient’s condition.
  • Complications or negative reactions
  • Factors that influence the intervention’s outcome.
  • Progress toward specified objectives.
  • Communication with other healthcare practitioners, the patient, and the patient’s family.
Lower Back Pain Soap Note Examples.

Lower Back Pain Soap Note Examples



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