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Pain Flow Sheet: Cognitively Intact

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

Pain Flow Sheet (Cognitively Intact) - PDF Version

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The developers of GeriatricPain.org have attempted to confirm the accuracy of all resources presented on this website. However, use of the information provided remains the responsibility of the individual clinician. Health care providers should use their clinical judgment in each situation and consider factors such as the patient’s age, medical condition, and the benefits versus risks of a suggested treatment.

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