Demographic data:
Name, Age, Location
Referral source:
GP/Specialist/Follow on
Summary and Formulation:
An introductory statement of salient demographic data. A brief summary of the most important features of history and examination. Diagnoses.
- Predisposing - Precipitating - Perpetuating - Aggravating
- Relieving factors
Sophisticated formulations illustrate
How influential are these factors?
How do they relate to the disease, suffering and function of the patient
What are the dynamic interaction of the biological, psychological and social components of the case (e.g. what psych things may stop them doing therapy)
How may these things affect long term outcomes
Management plan (immediate, short and long term)
- Non-professional influences / care providers (e.g. family)
- Involvement of allied health
- Pharmacological and medical follow up including referrals
- Procedures recommended
- Consider limitations in management (e.g. medication unavailable)
- Follow up planning
Presenting complaint:
History of presenting complaint:
(LINDOCARRF - remember intensity at rest and activity)
Impact of pain on life: (ADLs, Social)
Current and past pain treatments: (Pharmacological, interventional, psychological/allied health, complementary, OTC)
Occupational impact and history: (Including legal/claims, past jobs, current financial income etc).
PMHx/PSHx (other):
Medications (Analgesia):
Medications (Other):
Allergies:
Family history: (If relevant)
Social history: (HEADSS) (don't forget substances)
Psychological history:
- Formal diagnoses
- Supportive factors (Coping, Self efficacy, Locus of control)
- Maladaptive factors (Catastrophising, Fear avoidance)
- Suicidal screen
Forensic history: (if relevant)
Examination
Physical – pain orientated, functional and other relevant
Mental state
Investigations
Positive and negative, past and pending or to be ordered
Diagnostic List (with Taxonomy Framework) - (IASP, DSM 5, ICD-11)
Terminology to utilise:
High external or internal - Locus of control:
Pain generator:
Coping strategies:
Catastrophising:
Adaptive and maladaptive strategies:
Fear-avoidance behaviours:
Passive versus active treatments:
Social withdrawal:
Uses aids and displays pain:
Negative cognitions: (High external locus of control)
Positive cognitions: (Divert, self 'talk', ignore)
Self-efficacy:
2-1-3 - Discuss the application of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) concepts to people experiencing pain.
2-1-10 - Adapt assessment techniques to vulnerable populations, including but not limited to: - Children - Older persons
- Persons with cognitive, behavioural, mobility or communication impairments
- ATSIH
2-1-16 - Describe the differences between active and passive modalities of therapy.
Kommentare