Pain Reassessment Documentation: What to Record After an Intervention
The short answer
A pain note should let the next nurse see what the pain was, what you did, how the patient responded and what happens next. The key is a timed reassessment using the same tool as the first assessment, so the two numbers can be compared. "Pain relieved" with no number and no time is not enough.
The four parts of the record
- Initial assessment: location, onset, quality, intensity on a validated tool, what makes it better or worse, and the patient's own words.
- Intervention: the medication, dose, route and time, or the non-drug measure (positioning, heat or cold, distraction), as your workplace documents it.
- Reassessment: the time and result using the same tool, plus any side effects you watched for.
- Plan or escalation: if the pain is not controlled, who you informed, what was ordered and when you will reassess again.
Use the right tool for the patient
Employers choose which validated tools to use. Common examples include a 0 to 10 numeric rating scale for adults who can self-report, a faces scale for some children, and behaviour-based tools for people who cannot report pain. The Registered Nurses' Association of Ontario published the fourth edition of its pain best practice guideline in February 2025, covering prevention, assessment and management across the lifespan; its guidance is not binding and should be applied to local circumstances.
When to reassess
Timing depends on the intervention, the route, the patient and your employer's policy, which may also require monitoring such as sedation level or breathing after certain medications. This page does not give timings; use your policy and the prescriber's orders. What matters for documentation is that the time of the reassessment is recorded, not guessed.
A fictional example
"09:10 Mr. H. reports sharp pain in right lower abdomen, 7/10 on numeric scale, worse with movement, better when lying still. Incision clean, dry. 09:15 Administered ordered analgesic ___ per MAR. Positioned on left side with pillow support. 09:55 Reassessed: pain 3/10 at rest, 5/10 with movement. No nausea. Alert and talking. Encouraged to call before activity. Will reassess at ___ and before ambulation."
Both numbers use the same scale, both have times, and the note shows what the patient said and what was done.
Common mistakes
- "Pain relieved" with no score.
- Using a different scale at reassessment.
- Leaving out the reassessment time.
- Not documenting a non-drug measure that helped.
- Recording pain as "none" because the patient looks comfortable without asking.
- Failing to record who you told when the pain did not respond.
A fill-in template
Time: ___ Location/quality/onset: ___
Score and tool: ___ Patient's words: ___
Intervention and time: ___
Reassessment time and score (same tool): ___
Side effects/other observations: ___
Escalation or next check: ___
Where Fiabita fits
Fiabita's rewrite tools can help restructure rough notes into clearer wording, and you review every line before it goes in a chart. Fiabita does not know your employer's policy, cannot certify that a note is compliant and does not replace clinical judgment.
FAQ
Q: How soon must I reassess pain?
Follow your employer's policy and the prescriber's orders. This page does not set times.
Q: What if the patient cannot give a number?
Use the behavioural tool your workplace has adopted and say which one you used.
Q: Do I record a pain score every time?
Follow your employer's policy for frequency and the situations that need it.
Sources and further reading
- RNAO: Pain: Prevention, assessment and management (fourth edition, 2025)
- CNO Documentation practice standard (revised September 2025) — Ontario standard, useful as a model elsewhere; check your own regulator