Pain Assessment & Reassessment Nursing Note Example
A pain note documents the patient's reported pain, the interventions performed, and the reassessment that follows.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
Pain is subjective, so the patient's own rating and description are the core data. Pairing every intervention with a timed reassessment using the same scale lets a reader see whether it helped.
When this may be used
- When pain is assessed, treated, and reassessed.
- Reassessment timing varies by intervention and facility policy.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Components
Initial assessment
Baseline.
What belongs here
- Rating on the scale used, location, quality, onset
What does not belong
- Your estimate as their rating
Intervention
Care.
What belongs here
- Medication per order and nonpharmacologic measures performed
What does not belong
- Doses not given
Reassessment
Outcome.
What belongs here
- Time and rating on same scale
What does not belong
- "Resting comfortably" if not observed
Short fictional example
- Data
- Patient rates low back pain 7/10, "aching."
- Action
- Warm pack applied per order; repositioned on right side.
- Response
- 45 minutes later, patient rates pain 4/10.
More detailed fictional example
- Narrative
- 0900: Patient rates incisional pain 7/10, "sharp when I move." Oxycodone 5 mg by mouth given per PRN order. Pillow splinting reviewed; patient demonstrated splinting incision when coughing. 1000: Patient rates pain 3/10 at rest and 5/10 when moving.
Annotated example
Notes on the detailed example above:
"sharp when I move."
— The patient's own description.1000: Patient rates pain 3/10 at rest and 5/10 when moving.
— Reassessment on the same scale, with context.
Common mistakes
- Giving an intervention with no reassessment.
- Using different scales before and after.
- Writing "resting comfortably" without actually observing it.
Good vs poor documentation
Weaker (fictional)
Pain med given, effective.
Stronger (fictional)
0900: pain 7/10; oxycodone 5 mg by mouth per PRN order. 1000: pain 3/10 at rest.
Why: Measurable before and after.
Blank educational template
Pain assessment & reassessment: Pair every intervention with a reassessment. Prompts only; nothing is prefilled.
- Initial assessment
- [Rating, location, quality, onset/duration as obtained]
- Intervention
- [Pharmacologic and nonpharmacologic measures actually performed]
- Reassessment
- [Time and findings of reassessment]
- Follow-up
- [Further actions or notification, if any]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
- DAR notes
- Medication response
- SOAPIE notes
- Dosage Calculator — Medication math for doses you document.
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.