Pain Assessment Chart

Purpose: This chart is used to assess and track a patient's level of pain over time. It includes both visual analog and numeric rating tools to assist medical personnel in evaluating and documenting pain efficiently.

Patient Information

• Full Name: {name}
• Patient ID: {patientId}
• Date of Birth: {dateOfBirth}
• Exam Date: {examDate}

Pain Description

Location of Pain: {painLocation}

Type/Quality of Pain: {painType}

Duration of Current Pain Episode: {painDuration}

Triggers or Relieving Factors: {triggersOrRelief}

Pain Intensity Scale

Please indicate patient's current pain level using the following scale: 0 - No pain, 10 - Worst possible pain

Observations

{observations}

Interventions

Medications Administered: {medications}

Non-Pharmacologic Interventions: {nonPharmacologic}

Response to Treatment

{responseToTreatment}

{#followUpRequired}

Follow-Up Plan

• Next Evaluation Date: {nextEvaluationDate}
• Responsible Staff: {responsibleStaff}

{/followUpRequired}

Completed by: {completedBy}

Role/Position: {position}

Date: {completedDate}