Pain Assessment Tool - University of Pennsylvania School of NursingGenesis Eldercare Used to record pain assessments interventions and outcomes for patients enrolled in the ElderCare palliative care program 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date, ID number, and room number at the top of the form.
3. Indicate whether the patient has a diagnosis likely to cause pain by selecting 'Yes' or 'No'.
4. Check any applicable conditions from the provided list that may contribute to pain.
5. Specify if the patient is currently receiving pain medications by selecting 'Yes' or 'No'.
6. Mark the location of pain on the drawing provided and indicate any radiation direction with an arrow.
7. Assess and record the severity of pain using the Pain Severity Scale for both present and worst experiences over the last 24 hours.
8. Document frequency of pain complaints per day and note whether onset was chronic, acute, sudden, gradual, or trauma-related.
9. Evaluate how pain affects daily activities and quality of life by circling relevant descriptors.
10. Complete sections on pain quality description and non-verbal expressions for comprehensive assessment.

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