Patient Name                              Provider Name                          Room #               MR#                 
Date Time Pain Rating Location of Pain Activity Level * Character of Pain § Medication Non-Drug Therapy ^ Time Pain Rating after 1-2 hr Arousal level after 1-2 hr + Initials

 *Activity Level: A=Ambulatory, B=Bed, WC=Up in wheelchair, BR=Up to bathroom, M=Meal, C=Chair, R=ROM

§Character of Pain: A=Aching, D=Dull, T=Throbbing, B=Burning, Sh=Shooting, ST=Stabbing

^Non-Drug Interventions: 1=Repositioning, 2=Dim light/Quiet Environment, 3=Hot/cold Application, 4=Distractions, 5=Music, 6=Massage, 7=Other

+Level of Arousal: 0=Fully awake, 1=Relaxed, 2=Drowsy, 3=Difficult to arouse, 4=Stuporous, 5=Semi-Comatose


Adapted from Pain Management Algorithm Resource Manual

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