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Pain Assessment and Documentation

Clinical Indications: Last update 02/2009

    Any patient with pain.
    Definitions:
    Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
    Pain is subjective (whatever the patient says it is).

Procedure:

    1. Initial and ongoing assessment of pain intensity and character is accomplished through the
    patient's self report.

    2. Pain should be assessed and documented in the PCR during initial assessment, before
    starting pain control treatment, and with each set of vitals.

    3. Pain should be assessed using the appropriate approved scale.

    4. Three pain scales are available: the 0 - 10, the Wong - Baker "faces", and the FLACC.

    0 - 10 Scale: the most familiar scale used by EMS for rating pain with patients. It is primarily for adults and is based on the patient being able to express their perception of the pain as related to numbers. Avoid coaching the patient; simply ask them to rate their pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst pain ever.

    Wong Baker FACES scale: this scale is primarily for use with pediatrics but may also be used with geriatrics or any patient with a language barrier. The faces correspond to numeric values from 0-5. This scale can be documented with the numeric value.

Competency Based Skill Requirements:

    Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System.

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