Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Assessment:
Pain Score: [Score] – Document the pain score using a validated scale appropriate for the patient’s level of communication (e.g., Numeric Rating Scale (NRS), Faces Scale, Behavioral Pain Scale).
Location: Indicate the primary location(s) of pain.
Characteristics: Describe the quality of pain (e.g., sharp, dull, burning).
Exacerbating/Relieving Factors: Identify activities, procedures, or interventions that worsen or improve the pain.
Pain Management:
Current Medications: List all pain medications the patient is currently receiving, including route, dosage, and frequency.
Non-pharmacological Interventions: Document any non-pharmacological pain management strategies being used (e.g., positioning, splinting, heat/cold therapy, relaxation techniques).
Effectiveness: Describe the effectiveness of current pain management strategies on pain scores and patient comfort.
Impact of Pain:
Functional Limitations: Note how pain is affecting the patient’s ability to participate in activities (e.g., coughing, deep breathing, physiotherapy).
Sleep Quality: Indicate if pain is disrupting the patient’s sleep patterns.
Psychological Impact: Mention any signs of anxiety, depression, or frustration related to pain.
Plan:
Goal: Define a realistic and measurable goal for pain control (e.g., NRS score below 5).
Medication Adjustments: Outline any planned changes to pain medication regimen, including route, dosage, or type of medication.
Non-pharmacological Interventions: Indicate plans for continued or new non-pharmacological pain management strategies.
Monitoring: Specify the frequency of pain reassessments and the method of pain scoring.
Communication and Coordination:
Document communication with the patient regarding pain management goals and strategies.
Mention collaboration with other healthcare professionals involved in pain management (e.g., physical therapist, respiratory therapist).
Additional Notes:
Include any relevant information not covered above, such as:
Procedural pain (e.g., pain from chest tubes, catheters)
Underlying conditions contributing to pain (e.g., surgical incisions, trauma)
Concerns about potential medication side effects or opioid dependence
Plan for Follow-up:
Outline the schedule for reassessing pain and adjusting the pain management plan as needed.