Pain Reassessment Note (Post-Intervention)

Pain Reassessment Note (Post-Intervention)

Date/Time of Note: [Date and time of documentation]

Date/Time of Reassessment: [Date and time reassessment performed]

Intervention Time: [Exact time of intervention / Intervention time not available in record—note source attempted: MAR, flowsheet, or patient report]

Location/Setting: [Unit/clinic/bed or setting]

Context & Baseline

[Reason for reassessment (e.g., post-op pain, breakthrough pain, procedural pain)]

Baseline: [Pain score and scale (e.g., 8/10 NRS) / baseline pain score not documented]; [Functional limitation if documented] (Do not infer if not documented.)

Intervention

[Pharmacologic: medication name, dose, route] / [Nonpharmacologic: modality and application] (Limit to 1–2 lines; detailed medication information resides in the MAR.)

Response

Pain: [Current score and scale]; [Location if relevant]; [Temporal pattern: improved / unchanged / worsened / rebounded]

Function: [Functional anchor relevant to setting: ability to deep breathe/cough, turn, ambulate, tolerate procedure, participate in therapy]; Comfort goal met: [Yes / Partially / No]

Patient statement: [Verbatim quote if patient expressed concerns about side effects, requested escalation, refused intervention, or reported pain discordant with observed comfort] (Include only if such statements were made.)

Safety checks (Required after opioids or sedating medications):
Sedation: [POSS / RASS / other scale] score [value]; RR [value]; SpO2 [value]% on [room air / supplemental O2]; Alertness: [description]; Adverse effects: [present findings or "none observed"—assess for somnolence, confusion, nausea, pruritus, dizziness] (If safety assessment not performed, document reason and mitigation plan.)

For patients unable to self-report: [Behavioral tool and score (e.g., FLACC, CPOT)]; Observable indicators: [grimacing, guarding, restlessness]; Proxy input: [family/caregiver report—label as such] (Include only when patient cannot self-report.)

(Do not document "pain improved" solely because patient is asleep; note observed state and what was or was not assessed.)

Assessment & Plan

Response: [Controlled/Improved / Partially controlled / Uncontrolled / Worsened / Unable to assess]

Plan: [Next steps based on response: continuation of regimen, additional intervention given, provider notification with timestamp, adverse effect mitigation, or escalation steps]; Next reassessment: [timeframe or trigger] (Keep to 2–4 lines. Omit patient education unless explicitly provided during this encounter.)