This customizable document, Pain Assessment Form (Sample), is taken from MCN Healthcare’s Pain Management Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

Health care organizations around the world utilize MCN’s compliant ready templates and workflow process tools to help them meet the latest changes in regulations and standards.

Here is some sample content from Pain Assessment Form (Sample):

	PAIN ASSESSMENT FORM Statement on Pain Management: All patients have a right to pain relief. During the assessment process, you will gather information on the existence of pain and its effect on many aspects of the patient. Since pain is rarely a static process, the assessment process is ongoing, not simply a one-time event. The information obtained in the assessment allows you to formulate a plan of care with goals related to pain management. Date: Patient's Name: Diagnosis: Physician: Nurse: Location: Intensity: Patient rates the pain. Scale used: Present: Best pain gets:...
Second excerpt:
	... Use patient's own words, i.e., prick, ache, burn, throb, pull, sharp Onset, Duration, Variations, Patterns: Manner of Expressing Pain: What Relieves the Pain? What Causes or Increases the Pain? Effects of Pain: Note decreased function, decreased quality of life. Accompanying symptoms i.e., nausea Relationship with others i.e., irritability Appetite Concentration Sleep Emotions i.e., anger, suicidal, crying Physical Activity Other Pain Management Plan: Additional Comments:...