Pain Flow Sheet: Cognitively Intact
| 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