Click-to-copy pain documentation for PTs and PTAs in skilled nursing. Free, no login.
Nursing is aware of the patient's pain and reports they are addressing it with medication per MD order.
Unable to Express – Patient does not have the ability express self verbally, no pain is demonstrated in any other means. Patient does demonstrate facial grimacing with ----.
Patient c/o --- of 10 pain at --- prior to session, decreasing to --- of 10 following --- min of therapeutic activity.
Patient c/o --- of 10 pain at --- with movement. Session modified to pain-free range; patient completed --- of the planned interventions.
PT applied moist heat to --- x --- min prior to therapeutic exercise to reduce pain from --- to --- of 10 and improve tissue extensibility.
PT applied cold pack to --- x --- min following therapeutic exercise to manage post-exertional pain; pain decreased from --- to --- of 10.
Patient c/o pain rated --- of 10 at --- ; nursing notified for pre-medication --- min prior to future sessions to optimize participation.
Patient pre-medicated --- min prior to session and tolerated --- min of therapeutic activity with pain remaining at --- of 10 or below.
Patient c/o --- pain radiating from --- to --- , consistent with --- ; findings communicated to the PT and MD notified.
PT provided education on the difference between therapeutic muscle soreness and injurious pain; patient verbalized understanding with --- accuracy.
Patient's pain limited ambulation to ---ft this date compared to ---ft last session; PT will address with the nursing and MD.
Patient c/o --- of 10 pain at rest and --- of 10 at worst over the past 24 hours per patient report.
PT used a graded activity approach to keep pain at or below --- of 10 throughout the session; patient completed all planned interventions.
Patient reports pain interferes with sleep --- nights per week and with therapy participation --- days per week.
PT trialed positioning with --- to offload --- ; patient reported pain decreased from --- to --- of 10 with the position maintained.
Patient c/o incisional pain at --- rated --- of 10; incision inspected and found --- . Nursing notified.
Patient c/o --- of 10 phantom limb pain; PT provided desensitization and mirror therapy x --- min with pain decreasing to --- of 10.
Patient c/o pain at --- that improved with --- and worsened with --- ; this pattern informs the interventions selected this session.
PT provided TENS to --- x --- min with parameters --- to modulate pain during therapeutic exercise; pain decreased from --- to --- of 10.
Patient reports pain rated --- of 10 has been unchanged for --- sessions despite intervention; PT will discuss with the PT and MD.
Patient c/o --- of 10 pain at the R shoulder during w/c propulsion; PT assessed and identified --- as a contributing factor.
PT educated patient on pacing and activity modification to manage --- pain; patient verbalized --- of --- strategies on recall.
Patient reports the numeric pain scale is difficult to use; PT transitioned to the Wong-Baker FACES scale and patient indicated ---.
Patient nonverbal; PAINAD score of --- observed during mobility, indicating --- pain. Nursing notified for assessment.
Patient c/o --- of 10 pain at --- ; PT deferred --- intervention this date and substituted --- to remain within tolerance.
Patient's pain decreased from --- of 10 at eval to --- of 10 this date, correlating with an increase in ambulation from ---ft to ---ft.