.PAIN_NORMAL

Skilled pain assessment: {site} pain {#}/10 [{scale}] at/below goal {#}; quality {...}; pattern {...}; function at baseline; regimen tolerated, no untreated adverse effects; bowel/sedation acceptable on opioid. RN judgment applied to apply a validated scale, evaluate the regimen, and screen adverse effects given {dx}. Continued skilled monitoring indicated.

.PAIN_OLDCARTS

Onset {...}; Location {...}; Duration {...}; Character {...}; Aggravating {...}; Relieving {...}; Timing {...}; Severity {#}/10 (best {#}, worst {#}); goal {#}; radiation {...}.

.PAIN_PAINAD

PAINAD {#}/10: breathing {0–2}; vocalization {0–2}; facial {0–2}; body language {0–2}; consolability {0–2}; observed during {activity}.

.PAIN_SKILL

Administered/coordinated {agent} per order; reassessed at {interval} {#→#}/10; nonpharm {positioning/heat-cold} applied; bowel regimen {initiated/reinforced}; sedation {score}; RR {##}.

.PAIN_TEACH

Reviewed ATC vs PRN dosing, opioid safety, and constipation prophylaxis with {pt/cg}; method {teach-back/return-demo}; mastery {##}%.

.PAIN_COORD

Provider notified at {time} re pain {#}/10 above goal and {adverse effect}; reported {content}; order received {regimen change}; reassessment {when}.

.PAIN_SAFETY

Call for pain above goal despite regimen, new/severe pain, or adverse effects; 911 for unarousable sedation or slowed breathing on opioids.

.PAIN_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.