The Joint Commission states that identification and management of pain is an important component of patient-centered care. A pain assessment of pain must include pain location, intensity, character, frequency, and duration. When assessing for pain, a nurse should use the same pain scale at each assessment.

How to Assess and Document Pain

To initiate the pain assessment, first ask:

  1. Do you have any pain or are you hurting anywhere?

The patient may respond with a single area that is hurting or there may be multiple ares. You must FOCUS on those areas individually and assess them each and document them.

Once the assessment has been initiated, we will then focus on the MNEMONIC device for pain (PQRST) to help us assess the patient's pain.

P - Provoking Factors

Find out any factors that started this pain. A good question to ask is:

  1. What causes you to have the pain? What makes it better or what makes it worse?

Things that can contribute to pain is coughing, constipation, repositioning, etc...

Q - Quality of Pain or Discomfort

When you assess the quality of pain or discomfort, you may use some descriptive terms to help you document it. You can provide the patient these terms to assist them in describing their pain if they are having trouble thinking of a word to use.
As an example, the question you would be asking is:

  1. Can you describe the pain, is it deep, superficial, crushing, stabbing, sharp, achy, dull, constant or intermittent?

Some terms to help describe quality of pain include:

  • Crushing
  • Twisting
  • Pulling
  • Stabbing
  • Tearing
  • Nauseating
  • Debilitating
  • Throbbing
  • Pulsating
  • Burning
  • Searing
  • Biting
  • Blinding

You may also use nonverbal ques that you note your patient exhibiting:

  • Grimacing
  • Pacing
  • Rocking
  • Restless Movements
  • Withdrawal from others
  • Guarding
  • Splinting
  • Fetal Positioning
  • Wincing
  • Any muscle tension

R - Region of Pain

To assess the location of the pain, the patient can point to the area that hurts.
Assess this by asking:

  1. Can you point to where the pain is and does it move or radiate anwhere else?
    Can you tell me where you are hurting and does the pain move or radiate anywhere?

S - Severity of Pain

The severity of the pain can be documented using a pain scale such as the FLACC, Wong-Baker FACES, or the Numeric pain rating scale. Use the appropriate scale and make sure that you continue using it as you reassess pain.

The question here to ask is:

  1. Can you please rate your pain on a 0 - 10 scale with 0 being no pain and 10 being the worst pain you have felt in your life?

Other alternative is giving an example of the other scales to help measure and document the severity.

T - Times

Find out if the pain is affecting the patient's ability to function and how often the pain is occuring.

The question to ask here is:

  1. Does the pain prevent you from [sleeping, eating (any ADLs), walking, working]. Does the pain change during the day?

Example Documentation:

0932: States left knee pain at a 6 on a 0 - 10 pain scale. Describes pain as a pulling burning pain that "radiates up to the front part of the thigh." States, "It only hurts when I try to walk and is constantly there but hurts more when I attempt to walk with physical therapy." ---- Mai Practice, RN