Pain: Facility Assessment Checklists - Primaris

Pain: Facility Assessment Checklists
A facility system assessment is a starting point for a quality improvement project. The checklists included in
this booklet will be most useful if you take a critical look at your current practices.
Directions for Pain: Facility Assessment Overview Questionnaire
• To be completed by a direct care or interdisciplinary team.
• Consult with appropriate staff in answering certain questions and completing checklists.
• If you answer “No” to any of the questions below, please proceed immediately to the checklist
referenced by the page after the question.
• If you answer “Yes” to a question, the process is always complete and done so consistently. Please
continue to the next question.
• If you answer “In Progress” to any of the below questions, the need is being addressed but needs improvement.
Pain: Facility Assessment Yes No In Progress
Does your facility have a process for when and how the staff will screen residents
for pain? (page 2) o o o
Does your facility complete a comprehensive assessment for pain for residents who
are found to have pain upon screening? (page 3) o o o
Does your facility have a process for developing and implementing a care plan for
pain for residents who have been found to have pain upon screening? (page 4) o o o
For residents who are being treated for pain, does your facility have a process for
monitoring their pain on at least a daily basis? (page 5) o o o
Does your facility have a process for reassessing a resident’s pain to determine if the
resident’s care plan is effective or needs revision? (page 6) o o o
Does your facility have a policy for pain assessment and management? (page 7)
o o o
Does your facility have initial and ongoing education on pain assessment and
management to both nursing and non-nursing staff? (page 8) o o o
When completing each checklist on the following pages:
• If you answer “Yes” to all of the questions, the process is always complete and done so consistently.
Continue to the next checklist.
• If you are not sure, or answer “No” to one of the questions, choose one or more elements on which to focus
your quality improvement.
• If you answer “Needs Improvement” to one or more of the questions, the process is not always complete
and/or not always done consistently.
page of 8

Pain: Facility Assessment Checklists page of 8
Pain: Screening for Pain
A screening assessment is a brief assessment or questions that determine if the resident has pain or the potential
for pain. It does not include a thorough assessment about the pain symptoms or reasons for the pain that needs
to be done if the resident is found to have pain upon screening.
Basic questions to use as a screening assessment:
1. Do you have pain now?
2. Do you have pain that recurs?
3. If unable to answer questions 1 and 2,
a) Is there evidence of pain?
b) Are there diagnoses that suggest potential for pain?
4. Are there diagnoses that suggest potential for pain?
Does your facility have a process for screening that addresses all the below listed areas?
Yes
No
Needs
Improvement
Does your facility have a policy and procedure for when and how the staff will
screen residents for pain?
o o o
Does your policy and procedure state that residents should be screened for pain at
the following times:
o o o
• Within 24 hours of admission o o o
• Within 24 hours of readmission o o o
• At each MDS assessment o o o
• With each change in condition o o o
If unable to answer questions 1 and 2, a) Is there evidence of pain? b) Are there
diagnoses that suggest potential for pain?
o o o
Do you have a variety of pain evaluation tools available to allow individualization
(e.g., the Faces, numerical, verbal scales, or the PAINAD tools for the cognitively
impaired)?
o o o
Are residents screened (assessed) using the tool determined to be appropriate for
each resident?
o o o
Completed by:________________________________________
Date:_______________________________

Pain: Facility Assessment Checklists page of 8
Pain: Assessing Pain
A comprehensive assessment for pain is done when pain is identified on screening, someone develops
new symptoms of pain, or worsening pain that warrants a thorough assessment for this new complaint or
improvement of the condition causing the pain.
Does your comprehensive pain assessment include all of the below elements?
Yes
No
Needs
Improvement
If pain is identified during screening, does your facility have a process that will lead
to a comprehensive assessment within 24 hours?
o o o
Are the following elements included in your comprehensive assessment? o o o
• Description of the pain o o o
• Location of the pain o o o
• Intensity/severity of the pain using an accepted pain scale o o o
• Frequency of pain o o o
• Current pain o o o
• Pain at its least o o o
• Pain at its worst o o o
• Aggravating factors (what makes it worse) o o o
• Alleviating factors (what makes it better) o o o
• Effects of the pain on the resident’s life (ADLs, sleep, appetite, physical activity,
emotions, mood, nausea)
o o o
• Current treatment o o o
• Response to current treatment o o o
When a comprehensive assessment is done, are all these elements completed and
recorded on your assessment form and in a timely manner?
o o o
Completed by:________________________________________
Date:_______________________________

Pain: Facility Assessment Checklists page of 8
Pain: Monitoring Pain
For residents who are being treated for pain, does your facility have a process for monitoring their pain on at
least a daily basis?
Does your facility’s process for monitoring pain include these components?
Yes
No
Needs
Improvement
Do you ask residents to rate their pain using a pain scale identified as appropriate
for the resident?
o o o
Does your facility use an appropriate pain scale to monitor for pain on a daily basis
for those with cognitive impairment (e.g., the PainAD scale)?
o o o
Do you use nonverbal cues to monitor for pain? o o o
Do you record a monitored pain scale score: o o o
• At least every 24 hours? o o o
• Before giving a prn pain medication? o o o
• Approximated 30 minutes after giving a prn pain medication? o o o
• With each complaint of pain? o o o
Do you have a system for tracking in the medical record the results of your
monitoring?
o o o
Completed by:________________________________________
Date:_______________________________

Pain: Facility Assessment Checklists page of 8
Pain: Reassessing Pain
Does your facility have a process for reassessing a resident’s pain to determine if the resident’s care plan is
effective or needs revision?
Does your facility’s process for reassessing the care plan for pain address all the below areas?
Yes No
Needs
Improvement
Does your facility have a policy and procedure defining when a comprehensive
reassessment of pain will be completed? (A complete reassessment should be
performed for any persistent or worsening pain.)
o o o
Does the reassessment include all the components in the comprehensive
assessment? (See page 4, Monitoring Pain)
o o o
Does your staff follow the policy and procedure for reassessing pain when the
resident is complaining of persistent or worsening pain?
o o o
Is the resident reassessed for pain at regular intervals after being assessed initially
as having pain?
o o o
Do you reassess residents who are taking increasing doses of prn medication
(including those who are also on regularly scheduled medications for pain)?
o o o
Completed by:________________________________________
Date:_______________________________

Pain: Facility Assessment Checklists page of 8
Pain: Developing Pain Care Plans
Does the plan of care for pain address all the below areas?
Yes
No
Needs
Improvement
If pain is identified in admission, is a plan of care put into place within 48 hours of
admission?
o o o
Does the care plan for any resident identified with pain include a pain control goal
as defined by the resident/caregiver/family member?
o o o
Does the care plan include education of the resident and family related to these
areas of pain management:
o o o
• Goal of therapy o o o
• Side effects (e.g., drowsiness) o o o
• Constipation o o o
• Overall treatment plan o o o
For residents with daily pain, does the plan provide for medication on a regular
schedule (e.g., around the clock), not just prn?
o o o
Does the plan provide for medication use by mouth if at all possible? o o o
Does the plan provide for using non-pharmacological approaches to pain
management (e.g., massage, music, aromatherapy, ice or heat, etc.)?
o o o
Does the plan provide for keeping the resident as mobile as possible? o o o
Does the plan address positioning and proper movement to minimize the resident’s
pain?
o o o
Does the plan provide for regular monitoring of resident’s response to pain
medications at least every 24 hours?
o o o
Does the plan outline when the reassessment of resident’s pain and responses to
pain will be completed?
o o o
Completed by:________________________________________
Date:_______________________________

Pain: Facility Assessment Checklists page of 8
Pain: Assessing Pain Management Policies
Does your facility’s policy for pain assessment and management include the following components?
Yes
No
Needs
Improvement
Does your facility’s policy include a statement regarding your facility’s commitment
to pain management?
o o o
Does your facility’s policy include screening, assessment, and reassessment of
residents for pain?
o o o
Does your facility’s policy include the goals of the pain assessment and
management program such as:
o o o
• Prompt assessment and diagnosis of pain o o o
• Specification of appropriate pain scale tools for both cognitively intact and
cognitively impaired residents
o o o
• Steps to be taken to monitor treatment effectiveness o o o
• Pain treatment techniques based on clinically accepted guidelines, including
non-pharmacological therapies
o o o
• Improving the resident’s well being by increasing comfort and reducing
depression and anxiety
o o o
• Optimize the resident’s ability to perform ADLs and participate in activities o o o
• Monitoring for side effects prevention/treatment related to the use of pain
medication (i.e., constipation, nausea, vomiting, sedation, respiratory depression)
o o o
Does your facility’s policy address who, how, and when pain management program
effectiveness should be monitored and evaluated?
o o o
Does your facility’s policy address a protocol for ongoing monitoring of pain? o o o
Does your facility’s policy address a protocol for communication of reporting of pain
to the designated MDS personnel to ensure correct coding?
o o o
Completed by:________________________________________
Date:_______________________________

Pain: Facility Assessment Checklists page of 8
Pain: Assessing Staff Education and Training
Does your facility’s education program for pain assessment and management include the following
components?
Yes
No
Needs
Improvement
Are new nursing staff assessed for their need for education on pain screening,
assessment, and management?
o o o
Are current staff provided with ongoing education on the principles of pain
management?
o o o
Does education staff provide discipline specific education for pain assessment and
management?
o o o
Is there a designated clinical “expert” available at the facility to answer questions
from all staff about pain assessment and management?
o o o
Does education take into consideration the personal, ethnic, cultural, and religious
beliefs surrounding pain management?
o o o
Is the education provided at the appropriate level for the learner (i.e., CNA vs. RN)? o o o
Does the education include staff training on documentation methods related to
pain (i.e., location, duration, intensity, frequency, aggravating/alleviating factors,
pain scales)?
o o o
Completed by:________________________________________
Date:_______________________________
Document available at www.primaris.org
MO-06-15-PAIN July 2006 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents
presented do not necessarily reflect CMS policy.