4. Key visit elements — in addition to the Pain assessment

In addition to the full Pain assessment (location, quality, intensity, pattern, and the general pain evaluation documented there), the pain-management overlay adds each visit:

• The pain score and, more importantly, its functional impact stated against the ordered goal — for example “pain 4/10, able to transfer and sleep, meeting the functional goal” — rather than “pain at baseline.”
• The sedation score (on the ordered scale) and the respiratory rate — the opioid-safety vitals — recorded with the timing relative to opioid doses.
• Naloxone presence and expiration and the caregiver’s ability to use it.
• Bowel status against the ordered interval and the effect of the bowel regimen (cross-reference Gastrointestinal).
• Opioid and adjuvant adherence, breakthrough-medication frequency against the ordered limit, and any request to escalate.
• A safety screen for concurrent alcohol or sedating agents and for safe storage and handling — framed as harm prevention, not accusation.
• Non-opioid and non-pharmacologic measures in use (positioning, heat or cold, activity, and adjuvant analgesics) and their effect.
• The effect of pain and its treatment on mood, sleep, and function (cross-reference Cognitive/Mental Status).