Pain, considered the fifth vital sign, is a required documentation element for both home care and hospice patients. If the patient's initial assessment or interim assessment reveals the patient is experiencing pain, then pain must be evaluated and documented every visit. If you would like an example of a detailed pain assessment form that may be used during the initial assessment and/or subsequent assessments, email your request to Lisa Van Dyck.

Documentation of PAIN within the Home Care Steps® Protocols:

• Pathway Overview (PO): The PO of each pathway has an "Assess/Observe" element available to select for "PAIN". If pain is a problem, then "Pain" should be selected or "Ö". The line to the right of "pain" on the PO should indicate the pain scale value that that the patient wants to be at on the pain scale the agency uses (0-5 or 0-10). By selecting "pain" on the PO, this indicates that a "pain" assessment and results should be documented every visit. If "pain" is not selected on the Pathway Overview, then a "pain assessment" may not be required every visit.
• Visit Notes: Because not every patient has pain, a detailed pain assessment section is not included on every visit note. However, there is a place to document "pain" on every visit note in the "Comments" column in the "Disease Process Care Element". Further, if the patient is on medication or other treatment for pain, then there is an intervention in the "Medication Care Element" that promotes evaluation of "effectiveness of medication/treatment for symptom control."

Add to the Visit Note additional "pain assessment" items: If your agency feels the need to ADD pain assessment detail to the visit notes, then see the following example from North Shore Home Health, New York. You may want to add these elements to the Disease Process OR the Medication Care Element - "comments" column - wherever it will fit best without moving the visit note to another page.

Pain Location: ____________ Type: ___________ 
Intensity (no pain) 0 1 2 3 4 5 6 7 8 9 10 (severe pain) Precipitating factors: ________________________ 
Control measures: __________________________ 
Best response to control measures: 
(best response) 0 1 2 3 4 5 6 7 8 9 10 (least response)

OR

ADD only the following to the VISIT NOTE: 
Pain location: ____________ Type: ____________ 
Intensity (no pain) 0 1 2 3 4 5 6 7 8 9 10 (severe pain)

AND ADD to PATHWAY OVERVIEW: 
Precipitating factors: ________________________ 
Control measures: __________________________ 
Best response to control measures: 
(best response) 0 1 2 3 4 5 6 7 8 9 10 (least response)

• Pain Management COSTEP: This CoStep is included in the Infusion Therapy pathway package. This CoStep may be used for any patient with pain, not only ones using infusion therapy for treatment. It focuses on expected outcomes of pain management.

Upgrade project: VNA First is currently modifying the Pain Management CoStep. We are adding "interventions/assessments" to this form. It will be similar in format to the Infusion Therapy CoStep/Flowsheet. This should meet or exceed the required detailed assessments/evaluations and outcome documentation for pain.

For those of you who have our "Reference Packet" for the clinicians, ADD this to the procedures for use. If you do not have our "Reference Packet", that you may print on half sheets, double side, laminate, insert key ring and provide to your clinician, email or call office to request "Upgrade Order Form".

If an agency has a mental health program that has specific Mental Health nurses visiting patients as well as Med/Surg nurses visiting the same patient, then two pathways may be used concurrently.