Same way you would determine on any other note...you have to pick out the HPI, ROS, PFSH, EXAM, and figure the MDM. If the elements are truly limited and straightforward, it may not be a level 5. Hard to know for sure without seeing a note!
They be dealing with complex pain-management issues, but it the documentation is not there, there is nothing you can do.
( I HATE SOAP notes!!)
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