SOAP note example: low back pain
Acute low back pain is usually benign, and the note's main job is to show that the dangerous causes were looked for: cauda equina, fracture, infection and cancer. A careful neurological exam written in full does most of that work. Below are two invented notes, one mechanical and one with sciatica, and a guide to each SOAP section.
Example: acute mechanical low back pain
S: 41-year-old man, 5 days of lower back pain after lifting boxes at home. Pain central and right-sided, worse bending and sitting, better lying down. No leg pain, numbness or weakness. No saddle numbness. Passing urine and opening bowels normally, no incontinence. No fever, weight loss, night sweats or night pain. No history of cancer, trauma, steroid use or injecting drug use. Taking paracetamol with limited effect. Works as a warehouse supervisor, currently at work on lighter duties. Worried it is a slipped disc. O: Walks without aid, guarded movement. Tender right paraspinal muscles L4 to S1, no midline bony tenderness. Lumbar flexion reduced by half. Straight leg raise negative both sides to 80 degrees. Power 5/5 in all lower limb groups. Reflexes knee and ankle 2+ symmetrical. Sensation intact to light touch L2 to S1. Perianal sensation not tested; no symptoms to prompt it. A: Acute non-specific (mechanical) low back pain. No red flags. No radiculopathy. P: 1. Explained good prognosis; imaging not needed. 2. Stay active, avoid bed rest, heat as helpful. 3. Ibuprofen 400 mg three times daily with food for up to 7 days; no stomach ulcer, kidney disease or asthma reported. 4. Physiotherapy self-referral information. 5. Review in 2 to 3 weeks if not settling. 6. Emergency care for numbness around the back passage or genitals, new bladder or bowel problems, or leg weakness.
Building each section of a back pain note
The Subjective part should cover mechanism, location, radiation below the knee, what eases and worsens the pain, and the red flag questions written as answered negatives: saddle anesthesia, bladder or bowel change, progressive weakness, fever, weight loss, night pain, cancer history, trauma, osteoporosis or long-term steroids, and injecting drug use. Work, mood and beliefs about the pain matter for recovery, and a stratification tool such as STarT Back can be scored here.
Objective needs gait, inspection, midline versus paraspinal tenderness, range of movement, straight leg raise with the angle, and a lower limb neurological exam with power, reflexes and sensation by level. If you examined perianal sensation or did not, say so.
The Assessment states the category (non-specific, radicular, or suspected serious pathology) and names the red flags as absent or present. The Plan covers explanation, activity advice, analgesia with contraindications checked, physiotherapy, work advice, imaging only if indicated, review and explicit emergency advice.
Example: sciatica
S: 47-year-old woman, 3 weeks of left buttock pain radiating down the back of the leg to the outer foot. Tingling in the little toe. No weakness. Bladder and bowel normal, no saddle numbness. O: Straight leg raise positive left at 40 degrees. Power 5/5. Left ankle reflex reduced. Reduced light touch on the lateral left foot. A: Left S1 radiculopathy, likely disc-related. No motor deficit or cauda equina features. P: Analgesia reviewed. Physiotherapy referral. MRI if not improving by 6 weeks or earlier if weakness develops. Emergency advice for cauda equina symptoms given and understood.
Documentation gaps in back pain
- Red flags asked but not written, or written as "no red flags" with no detail.
- Neurological exam summarized as "neuro intact" instead of power, reflexes and sensation.
- Straight leg raise result without the angle or side.
- No emergency advice about cauda equina symptoms.
- Imaging ordered without a documented reason.
ICD-10 codes for low back pain
| Code | Meaning |
|---|---|
| M54.50 | Low back pain, unspecified (ICD-10-CM; base ICD-10 uses M54.5) |
| M54.41 / M54.42 | Lumbago with sciatica, right side / left side |
| M54.16 | Radiculopathy, lumbar region |
| M51.16 | Intervertebral disc disorders with radiculopathy, lumbar region |
| S39.012A | Strain of muscle, fascia and tendon of lower back, initial encounter |
Low back pain codes changed in recent ICD-10-CM updates, so check your system's code list when M54.5 is rejected.
Getting the back pain note from ClearPass
Most of a back pain visit is the history and the exam you call out as you go. When you use Transcribe with the patient's agreement, ClearPass keeps the red flag answers and the findings you say aloud, and writes them in SOAP with a neurological exam laid out by power, reflexes and sensation. Choose Detailed if you want every negative kept.
If the note carries an angle, a dose or a reflex grade you never said, the numbers check marks it. ICD-10 codes, patient instructions on activity and warning symptoms, a sick note or a physiotherapy referral are one click each. Read the draft and fix anything before it goes into the chart.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
How should red flags appear in a low back pain SOAP note?
As specific negatives in Subjective, such as no saddle numbness and no bladder or bowel change, with the Assessment stating that none were found. A bare 'no red flags' shows less.
Does acute low back pain need imaging documented?
If you decided against imaging, a line saying why helps. When imaging is ordered, the note should show the indication.
Can ClearPass write a physiotherapy referral from the same visit?
Yes. Referral letter is one click from the visit, written from what was said. You review it before sending.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
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