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PROGRESS NOTE Pain Assessment and Documentation Tool (PADT) Patient Stamp Here Patient Name: Record #: Assessment Date: Current Analgesic Regimen Drug name Strength (eg, mg) Frequency Maximum Total.

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Introduction. The Pain Assessment and Documentation Tool (PADT) is a two-sided chart note designed to be easily included in a patient's medical record and to facilitate ongoing evaluation of patient pain and documentation of pain management.

Patients should be asked to describe their pain in terms of the following characteristics: location, radiation, mode of onset, character, temporal pattern, exacerbating and relieving factors, and intensity. The Joint Commission updated the assessment of pain to include focusing on how it affects patients' function.

The WILDA approach to pain assessment—focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors—offers a concise template for assessment in patients with acute and chronic pain.

For the cognitively intact adult, assessment of pain intensity is most often done by using the 0 to 10 numeric rating scale or the 0 to 5 Wong-Baker FACES scale, or the VRS. Once patients know how to use a pain intensity scale, they should establish “comfort-function” goals.

What to record Time and date. Recent activities and potential triggers. Changes in medical conditions. Changes in medications. Recent pain experienced (location, intensity and duration) Effect of any pain relief medications or techniques used. Emotional or psychological effects of pain.

Pain Assessment Scales Numerical Rating Scale (NRS) Visual Analog Scale (VAS) Defense and Veterans Pain Rating Scale (DVPRS) Adult Non-Verbal Pain Scale (NVPS) Pain Assessment in Advanced Dementia Scale (PAINAD) Behavioral Pain Scale (BPS) Critical-Care Observation Tool (CPOT)

Six Tips to Documenting Patient Pain Tip 1: Document the SEVERITY level of pain. ... Tip 2: Document what causes VARIABILITY of pain. ... Tip 3: Document the MOVEMENTS of the patient at pain onset. ... Tip 4: Document the LOCATION of pain. ... Tip 5: Document the TIME of pain onset. ... Tip 6: Document your EVALUATION of the pain site.

Chronic pain assessment should include determining the mechanisms of pain through documentation of pain location, intensity, quality and onset/duration; functional ability and goals; and psychological/social factors such as depression or substance abuse.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232