Assessments should be simple and easily documented in a manner that promotes good communication. Let's review some options. Using pain assessment scales Besides facilitating continuity of care, a pain scale lets patients describe pain in a way that's meaningful to them. Your facility should have scales suited to various patients, depending on age, cultural background, literacy, and mental competency. If possible, teach your patient about pain scales when she isn't in pain.
Scales can be horizontal or vertical, depending on the patient's preference.
Also discuss her pain-control goals. If she's scheduled for major surgery, inform her that complete pain relief may not be possible immediately after surgery but that you'll help minimize discomfort as much as possible. Agree with her on a pain rating goal and work with her to achieve it. Keeping a pain assessment flow sheet may be helpful. Document the pain assessment tool used, the patient's score, analgesics administered, any adverse reactions, comfort measures, patient education, and the patient's response to treatment.