Tip 1: Document the SEVERITY level of pain
On a scale of 1-10 (with 10 being the worst)
, how much pain
does the patient
report experiencing?
Tip 2: Document what causes VARIABILITY of pain
What increases the pain (movement, palpation, bearing weight, etc.) and what reduces the pain (ice, elevation, not moving the affected area, etc.)?
Tip 3: Document the MOVEMENTS of the patient at pain onset
What was the patient doing at the onset of pain (e.g. mowing lawn before onset, climbing a ladder and fell down, sleeping and was awakened by pain, etc.)?
Tip 4: Document the LOCATION of pain
What is the specific location of the pain? Be as specific as possible and include the laterality of the pain (which side of the body, and which specific body part is experiencing pain: e.g. pain is in the lower right arm, instead of just saying "arm pain"). Medicare and several other insurances require laterality when coding for insurance claims. If patient is experiencing abdomen pain symptoms, document which quadrant of the stomach is the pain is located in (e.g. patient is experiencing pain in the lower left quadrant of the stomach).
Tip 5: Document the TIME of pain onset
What time or how long ago did the patient report the pain starting? Remember to be specific!
Tip 6: Document your EVALUATION of the pain site
What did you find at the pain site? Was there swelling, deformity, bruising, tenderness, etc.? Was the patient guarding the area of pain?
