Pain Monitoring Chart

Sticky label
Patient Name Patient CHI

Pain Sites
A B C

¾ Complete an initial pain assessment sheet

¾ Complete this pain monitoring chart each visit/day
¾ Ask the patient: On a scale of 0-10, what is the worst pain you have had in the last 24 hours?
¾ Record a pain score 0-10 for each site or as mild/moderate/severe if the patient cannot give a number
OR record the patient’s overall worst pain score (Z) as 0-10 or in words
¾ Check for opioid toxicity: drowsy, myoclonic jerking, vivid dreams, touch sensitivity
¾ Assess the impact of the pain on the patient
¾ Record current treatment and details of any changes to medication

Worst pain score in past 24 hours 0-10

Date/time
10
9
Severe (S)
8
7
6
5
Moderate (D) 4
3
Mild (M) 2
1

No Pain
Unable to score
Opioid toxicity Y/N

Impact of pain on patient

Severe
Moderate
Mild
None

Treatment
Staff
Paracetamol NSAID Regular Opioid Breakthrough Adjuvant Laxative
Sign
None None None None None None

Comments

Date changed:
Staff
Paracetamol NSAID Regular Opioid Breakthrough Adjuvant Laxative
Sign
No Change No Change No Change No Change No Change No Change

Comments
Pain Monitoring Chart continued
Sticky label
Treatment Changes

Date changed:
Staff
Paracetamol NSAID Regular Opioid Breakthrough Adjuvant Laxative
Sign
No Change No Change No Change No Change No Change No Change

Comments

Date changed:
Staff
Paracetamol NSAID Regular Opioid Breakthrough Adjuvant Laxative
Sign
No Change No Change No Change No Change No Change No Change

Comments

Date changed:
Staff
Paracetamol NSAID Regular Opioid Breakthrough Adjuvant Laxative
Sign
No Change No Change No Change No Change No Change No Change

Comments

Date changed:
Staff
Paracetamol NSAID Regular Opioid Breakthrough Adjuvant Laxative
Sign
No Change No Change No Change No Change No Change No Change

Comments

Date changed:
Staff
Paracetamol NSAID Regular Opioid Breakthrough Adjuvant Laxative
Sign
No Change No Change No Change No Change No Change No Change

Comments