Select a validated scale matched to the patient: a 0–10 numeric or verbal descriptor scale for those who can self-report; the Wong-Baker FACES scale where preferred; and an observational scale (for example PAINAD — breathing, vocalization, facial expression, body language, and consolability) for nonverbal or advanced-dementia patients.
Use a structured framework (OLDCARTS or PQRST) to capture onset, location, duration, character, aggravating and relieving factors, radiation, timing, and severity.
Assess functional impact directly — observe or ask about specific activities limited by pain.
Reassess after an intervention at an interval appropriate to the route and agent (commonly 30–60 minutes after an oral analgesic), and document the effect.
Screen for analgesic adverse effects each visit, including sedation level and, for opioids, respiratory status and bowel function.
