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Pain Assessment

Pain Assessment 

 

Resident Name:  _____________________________________________                  Date:  ______________________________ 

 

Primary pain site:  ___________________________________________________________  Date of pain onset  _____/_____/_____ 

                                            (Indicate on body illustration as Site A) 

 

Brief pain history (resident’s viewpoint or observation)  _______________________________________________________________ 

 

Location/origin of pain  ________________________________________________________________________________________ 

 

Pain relief methods tried (check all that apply):     o Medication   o Deep Relaxation   o Heat    o Cold    o Massage 

o Meditation    o Music    o Visual Imagery    Other (specify)  _________________________________________________________ 

 

Pain is relieved by (describe)  ___________________________________________________________________________________ 

 

Pain is worsened by (describe circumstances or activities)  ____________________________________________________________ 

 

___________________________________________________________________________________________________________ 

 

Times when pain is worse: o Early Morning (pre dawn)    o Morning     o Afternoon     o Evening     o Night 

 

Activities pain prevents residents from doing  ______________________________________________________________________ 

 

Associated symptoms (if any)  __________________________________________________________________________________ 

 

Comments  _________________________________________________________________________________________________ 

 

___________________________________________________________________________________________________________ 

 

 

Image removed.Image removed.Image removed.Image removed.            On a Scale of 0 – 10, please rate the resident’s pain: 

 

         0                  1-3                4-6               7-10 

     No Pain     Mild Pain  Moderate Pain  Severe Pain                                    _____________________ 

 

Items 

Score 

Breathing Independent of Vocalization 

Normal 

Occasional labored breathing, short period of hyperventilation. 

Noisy labored breathing, long period of hyperventilation. 

 

Negative Vocalization 

 

None 

Occasional moan or groan, low level speech with a negative disapproving quality. 

Repeated troubled calling out, loud moaning or groaning, crying. 

 

Facial Expression 

 

Smiling or inexpressive 

Sad, frightened, frown 

Facial grimacing. 

 

Body Language 

 

Relaxed 

Tense, distressed, pacing, fidgeting. 

Rigid, fists clenched, knees pulled up, pulling or pushing away, striking out. 

 

Consolability 

 

No need to console 

Distracted or reassured by voice or touch 

Unable to console, distract or reassure. 

 

 

Total Score 

 

 

Score Each Item Individually and Add for Total Score (0-10) 

 

 

Nurses Signature:  _________________________________________________ 

 

References: 

  • Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM] 

  • CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines] 

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