Pain is whatever the experiencing person says it is, existing whenever they say it does — so your job is to measure it, not to judge it. Match a validated tool to the patient in front of you, read the mechanism out of the words the patient chooses, and score sedation with POSS, because sedation always arrives before the respiratory rate falls.
Which tool do you use?
Self-report is always the gold standard, so ask first: can this patient self-report? If not, you must use a validated observational tool — and you must never chart “denies pain” for a patient who cannot answer.
What mechanism do those words point to?
The words the patient chooses point to the treatment, so those exact words belong in your note. Classify, then read why it changes the prescription.
1 · What does the patient rate the pain right now?
8severe
2 · You gave the ordered analgesic. By what route?
3 · You come back. What do you see?
4 · Score the sedation with POSS
5 · What do you do?
Choose a toolRead the patient on the left, then select.
Classify the painSomatic, visceral or neuropathic?
Live pain recordScore, reassessment window and sedation.