How To Document Pain Assessment

Pain Assessment

Pain affects more than 100 million Americans and costs more than $600 billion annually, according to a new study published in Pain Physician. Reports from The American Academy of Pain Medicine indicate that the financial impact of chronic pain on the US economy is greater than diabetes, heart disease and cancer combined. As pain medicine specialists strive to provide quality care, they have to pay attention to the financial aspects of their practice. Accurately documenting the patient’s pain is essential to improve coding and maximize reimbursement. Pain management transcription services play an important role in helping physicians ensure complete, accurate and up-to-date clinical documentation.

Telling the Patient’s Story with Detailed Documentation of Pain

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Thorough, detailed documentation of pain is crucial for the following reasons:

  • Assists in diagnosis and development of an effective treatment plan
  • Supports continuity of care by providing detailed better, more effective information to other health care providers treating the patient
  • Leads to accurate coding for appropriate and timely claims payments

What should the documentation include? As pain is multidimensional, the assessment of pain must include the intensity, location, duration and description, the impact on activity.

PQRST for Pain Assessment: As pain is a subjective and a unique subjective experience with multiple dimensions that may not be directly apparent to others or measured by physiological tests, pain assessment depends significantly on self-report. The PQRST method is considered the Gold Standard to assess and document a patient’s pain.

Precipitating and relieving factors – The patient is asked what they were doing when the pain started, what caused the pain, what makes it better or worse, and what seems to trigger it.

Quality – What is the quality, character, and intensity of the pain – sharp, dull, burning, or other?

Radiate – Ask the patient if the pain is localized or moves to other sites, and if so, where else they feel pain.

Severity – The patient is asked to rate the pain on a scale of 0 to 10, where 0 is no pain, and 10 stands for the worst pain ever.

Timing – Questions relate to all temporal aspects: When/at what time the pain started, duration, frequency, such as hourly, daily, weekly, or  monthly, if it is sudden or gradual, whether it is seasonal, and so on.

In addition to the severity, variability, patient’s movements at pain commencement, location, and time of pain onset, the physician should also document the evaluation of pain site. This assessment should describe any swelling, deformity, bruising, tenderness, and so on.

Point to note: While a self-report by the patient has conventionally been the basis of pain assessment, communication barriers such as cognitive impairment or language barriers can make this difficult. Caregiver reports may be used as a proxy in such situations. As pain is also difficult to measure accurately and reliably in children, parents or family caregivers may have to be involved in the assessment.

Progress Notes to Chart the Patient Experience

One of the most important documents that a medical transcription service company helps pain specialists create is the progress note. It is essential that pain assessment is done on a regular basis using a standard format to monitor the patient’s progress. It involves documenting pain after each intervention to assess its impact, understand the patient’s experience, and determine whether the treatment should be modified.

Progress notes document the patient’s recovery and care and serve as a record for the patient’s time spent in the hospital’s or clinic’s care. Healthcare professionals use the SOAP method (subjective evidence, objective information, assessment, and care plan) to write progress notes. Progress notes can also include an interventions section where nurses can include additional information about interventions such as medications administered during their shift and observations made about the patient.

However, medical records often miss circumstances, details and nuances and this loss can be more pronounced in patients dealing with pain.  Recent studies have found that applying natural language processing (NLP) technology to an EHR dataset could successfully and efficiently capture detailed pain information from clinical notes (Automated Extraction of Pain Symptoms: A Natural Language Approach using Electronic Health Records (Pain Physician, 2022).

Role of Pain Management Medical Transcription Services

Pain management has extensive documentation requirements when it comes to insurance payment. For instance, take Medicare requirements for chiropractic services. Medicare requires that the record should document symptoms that bear a direct relationship to the level of subluxation. The symptoms should refer to the spine, muscle, bone, rib and joint and should be reported as pain, inflammation, or as signs such as swelling, spasticity, etc.

In addition to documentation of subluxation shown by x-ray or physical exam, the documentation must show at least 2 elements of:

  • Pain
  • Asymmetry/misalignment
  • Range of motion abnormality
  • Tissue tone changes (P.A.R.T.), including 1 that falls under asymmetry/misalignment or range of motion abnormality
  • Include dated documentation of the first evaluation
  • Include primary diagnosis of subluxation (including level of subluxation)

The provider should also include any documentation supporting medical necessity

Medicare also requires that family and past health history, including general health, prior illness, injuries, hospitalizations, medication, and surgical history be elicited from the patient and documented on initial examination.

Extensive documentation requirements can take up physician time. Medical Economics recently reported on a new study which found that physicians spend an estimated 4.5 hours a day completing electronic health records (EHR), which “leaves less time to attend directly to patients” (

Partnering with a medical transcription company that specializes in pain transcription is a practical solution to this problem. Experts can ensure consistent, accurate and timely EHR documentation, allowing physicians to focus on their patients.