Which of the following needs to be included when documenting a pain assessment?
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 We know you take good care of your patients. You know you take good care of your patients. But insurance companies reimbursing your claims don’t know how well you take care of your patients. It’s up to you to tell them. What’s the best way to do this? A detailed assessment of the patient and the patient’s chief complaint during transportation. Part of this necessary assessment process is completely and accurately documenting the patient’s pain. Following these tips when documenting patient pain does double duty by a) allowing the receiving facility to get a complete and accurate picture of the patient’s pain in order to give quality continued care, and b) increasing the likelihood of your claims getting paid by insurance companies. Tip 1: Document the SEVERITY level of pain On a scale of 1—10 (with 10 being the worst), how much pain does the patient report experiencing? Tip 2: Document what causes VARIABILITY of pain What increases the pain (movement, palpation, bearing weight, etc.) and what reduces the pain (ice, elevation, not moving the affected area, etc.)? Tip 3: Document the MOVEMENTS of the patient at pain onset What was the patient doing at the onset of pain (e.g., mowing the lawn, climbing a ladder and fell down, sleeping and was awakened by pain, etc.)? Tip 4: Document the LOCATION of pain What is the specific location of the pain? Be as specific as possible and include the laterality of the pain–which side of the body, and which specific body part is experiencing pain (e.g., pain is in the lower right arm, instead of just saying “arm pain”). Medicare and several other insurances require laterality when coding for insurance claims. If patient is experiencing abdomen pain symptoms, document which quadrant of the stomach the pain is located in (e.g., patient is experiencing pain in the lower left quadrant of the stomach). Tip 5: Document the TIME of pain onset What time or how long ago did the patient report the pain starting? Remember to be specific! Tip 6: Document your EVALUATION of the pain site What did you find at the pain site? Was there swelling, deformity, bruising, tenderness, etc.? Was the patient guarding the area of pain? *Have any documentation questions? Email Grant Helferich, Omni EMS Billing‘s documentation expert.
Grant Helferich is employed as the EMS Advisor/Client Trainer with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator’s Society. He was certified as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked EMS for over 35 years in roles such as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS. “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1968, cited in Rosdahl & Kowalski, 2007, p. 704). Pain is a subjective experience, and self-report of pain is the most reliable indicator of a patient’s experience. Determining pain is an important component of a physical assessment, and pain is sometimes referred to as the “fifth vital sign.” Figure 2.1 Example of a pain scalePain assessment is an ongoing process rather than a single event (see Figure 2.1). A more comprehensive and focused assessment should be performed when someone’s pain changes notably from previous findings, because sudden changes may indicate an underlying pathological process (Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014). Always assess pain at the beginning of a physical health assessment to determine the patient’s comfort level and potential need for pain comfort measures. At any other time you think your patient is in pain, you can use the mnemonic LOTTAARP (location, onset, timing, type, associated symptoms, alleviating factors, radiation, precipitating event) to help you remember what questions to ask your patient. See Checklist 14 for the questions to ask and steps to take to assess pain. Nurses can help patients more accurately report their pain by using these very specific PQRST assessment questions: P = Provocation/PalliationWhat were you doing when the pain started? What caused it? What makes it better or worse? What seems to trigger it? Stress? Position? Certain activities? What relieves it? Medications, massage, heat/cold, changing position, being active, resting? What aggravates it? Movement, bending, lying down, walking, standing? Q = Quality/QuantityWhat does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching. R = Region/RadiationWhere is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot? S = Severity ScaleHow severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last? T = TimingWhen/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally? DocumentationIn addition to facilitating accurate pain assessment, careful and complete documentation demonstrates that you are taking all the proper steps to ensure that your patients receive the highest quality pain management. It is important to document the following: What should be included in a pain assessment?Pain is multidimensional therefore assessment must include the intensity, location, duration and description, the impact on activity and the factors that may influence the child's perception of pain (bio psychosocial phenomenon) The influences that may alter pain perception and coping strategies include social history/ ...
What are the five key components of pain assessment?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.
When assessing pain What four factors should be noted and documented?Comprehensive pain assessment also includes pain history, pain intensity, quality of pain, and location of pain. For each pain location, the pattern of pain radiation should be assessed (NCI, 2016).
What is the most important part of a pain assessment?The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format.
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