How to Document Pain Reassessment
Pain reassessment is where many notes fall short. The first number is charted, an intervention is given, and the outcome is left out. A complete entry closes that loop.
The short answer
Chart the initial pain assessment, the intervention (drug, dose, route and time, or non-drug measure), a reassessment with the same tool, the patient's response in their words, any side effects, and what you did if pain was not controlled. The RNAO pain guideline says self-report is the most valid way to assess pain when a person can communicate, and that documentation affects the team's ability to judge whether the plan works.
Initial assessment: what to capture
- Location, onset, duration and quality, in the patient's words.
- Intensity using a validated tool suited to the patient, such as a numeric scale for adults who can self-report.
- What makes it better or worse, and its effect on sleep, movement or activities.
- For patients who cannot self-report, use a validated behavioural tool your employer specifies and say which one.
Reassessment: how it fits
Reassessment timing depends on the intervention, the patient's condition and your employer's policy, so follow that rather than a fixed rule. Use the same tool, record the time, and note the patient's response in their words. For patients receiving opioids, the RNAO guideline recommends routine sedation and respiratory assessments, so record those too where your policy requires.
Example (fictional patient)
Note
0900: Patient N states, "sharp pain in my right shoulder, worse when I lift my arm." Numeric scale 7/10. Shoulder not swollen, movement limited. Prescribed analgesic given PO at 0905; ice pack applied; arm supported on pillow. 0945: states pain "dull now," 3/10, can lift arm to shoulder height. Alert, RR 16, no nausea. Goal per patient: pain below 4 to join physiotherapy at 1030. 1030: pain 3/10, attended physiotherapy.
Common mistakes
- "Pain controlled" with no number or time.
- Switching tools between assessments so scores cannot be compared.
- No reassessment time after a medication.
- Charting "denies pain" when behaviour suggests otherwise, without noting the discrepancy.
- No action recorded when pain remains high, such as notifying the prescriber.
- Omitting side effects such as sedation or nausea.
If pain is not controlled
Record the score, your response (non-drug measures, notifying the prescriber, requesting a medication review), the time, who was told and what was ordered. An unaddressed high score looks like it was missed.
Template
Time: ___ Patient states: "___" Location and quality: ___ Score and tool: ___ Intervention (drug, dose, route, time or non-drug): ___ Reassessment time and score (same tool): ___ Response in patient's words: ___ Side effects and sedation or respiratory check: ___ Next step or who notified: ___
Where Fiabita fits
Fiabita's "Clean up my note" tool can help you reword rough notes into clearer, more objective language, and its SBAR handoff and incident-report tools ask guided questions so fewer details get lost under pressure. The output is a draft: you remain responsible for what goes into the record, and it does not check compliance with your regulator or employer. Do not enter information that could identify a real patient, and follow your workplace policy on which tools may be used.
FAQ
Q: How soon should I reassess?
Follow your employer's policy and the prescriber's orders. They vary with the drug, route and patient condition.
Q: What if the patient cannot report a number?
Use a validated tool your employer specifies for that situation, record which one, and chart what you observed.
Q: Is the pain score enough?
No. A score alone does not show function, response to treatment or side effects. Add a brief description and the plan.
Sources and further reading
- RNAO: Pain: Prevention, assessment and management (fourth edition, 2025)
- College of Nurses of Ontario: Documentation practice standard
- CNPS: Documentation for Nurses (guidelines)
Always check the current version of each source and your own regulator's standards; links and wording can change.