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Discharge Template Sample
Based on Medication Samples
Pain Status Template
Select as applicable
Reasons for Pain
Pain Exacerbation Factors
No Pain Information
Patient has no complaint of pain.
Pain is not a concern for the patient any day.
Patient takes OTC pain medications, only as needed.
Pain grade if patient complains of occasional low grade pain (number only)
on and off
Reason for pain
multiple sclerosis ;
rheumatoid arthritis ;
Other reasons for pain
weight bearing joints ;
diffuse body ;
small joints in extremities ;
upper back ;
lower back ;
wound site ;
Additional pain site
Pain exacerbation factors
weight bearing ;
inflamed joints ;
diffuse muscle spasms ;
Other pain exacerbation factors
Patient takes pain medications, only on an as needed basis.
Patient does not want to take any pain medications.
Patient would consider only alternative pain management strategies for pain control.
Patient has no prescription pain medications, but takes OTC pain medications.
Patient is on multiple medications for pain management.
Tylenol # 3 ;
Fentanyl patch every 72 hours ;
Additional Pain Medications
Recent changes with pain medications
no changes happened with pain medications
dose changes happened with pain medications
new pain medications are added
narcotic pain medications were discontinued
change happened in pain medication schedule to as needed basis
Side Effects of Pain Medications
difficulty breathing ;
Additional Side Effects
Please specify recent pain variation on a scale of 0-10 (number only)
Pain Level Today on a scale of 0-10 (number only)
Nerve pain in the extremities has been a recent complaint.
Neuropathy has been a chronic complaint.
Patient complains of nerve pain in both lower extremities.
Patient complains of nerve pain in all the extremities.
Patient has been started on medication to manage the neuropathy in the extremities.
Patient continues on antineuropathy medication for control of nerve pain reported.
Neuropathy Exacerbation Factors
poor control of blood sugars ;
relapse of multiple sclerosis ;
progression of disc degeneration ;
pinched nerves in the spine ;
peripheral vascular disease ;
poor blood supply to the distal extremities ;
chronic smoking ;
Other factors for exacerbation of neuropathy
Antineuropathy medications (name only)
Pain control response
Goals for Pain Management
Patient wants pain to be completely resolved and managed at 0 on a scale of 0 – 10.
Patient wants pain to be managed between 0 – 5, with no exacerbation beyond 6, on a scale of 0 – 10.
Patient wants to have the pain managed at a max of 2 – 3 on a scale of 0 – 10.
Patient wants to prevent any acute exacerbation of pain from happening.
Pain is well-controlled and patient has no goals with regards to pain management.