Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Documentation
  • Document on a standardized form that captures the person’s pain experience specific to the population and setting of care. Documentation tools will include: (Grade of Recommendation = C)
    • Initial assessment, comprehensive assessment and re-assessment.
    • Monitoring tools that track efficacy of interventions (0-10 scale) (Link to tools section of this PDA)
  • Document pain assessment regularly and routinely on standardized forms that are accessible to all clinicians involved in care.
  • Teach individuals and their families (as proxy recorders) to document pain assessment on the appropriate tools when care is provided. This will facilitate their contributions to the treatment plan and will promote continuity of effective pain management across all settings. (Grade of Recommendation = C)