Pain Assessment Documentation: Scales, OLDCARTS and Reassessment

Pain documentation should show what the pain is like, how it was measured, what was done and whether it worked.

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Choose and name the scale

Self-report is preferred when the patient can give it. Common tools include the 0 to 10 numeric rating scale and faces scales. For people who cannot self-report, behavioural tools are used, such as FLACC for young children and PAINAD for people with advanced dementia. Always record which tool you used.

Describe the pain

OLDCARTS is a common mnemonic: Onset, Location, Duration, Character, Aggravating and relieving factors, Radiation, Timing and Severity. PQRST is a shorter alternative: Provocation or palliation, Quality, Region and radiation, Severity, Timing.

Document the intervention and reassessment

Record medication and non-drug measures, then reassess within the timeframe your facility policy sets for that route. The reassessment entry should use the same scale as the original score.

Fictional example

09:00 Reports sharp pain right lower abdomen, 7/10 numeric scale, worse on movement. PRN analgesic given as ordered, repositioned with pillow support. 09:40 Pain 3/10, resting.