F-11
Pain Assessment & APS Daily Rounds Form
دليل السياسات والإجراءات في التخدير — Section M
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Acute Pain Service (APS) Daily Rounds Form

ANESTHESIA DEPARTMENT • FORM F-11 • CBAHI/JCI COMPLIANT
Patient Name: MRN: Date: Time:
Age: M F   Wt: kg BMI: Room/Bed: Service: POD:
Procedure/Surgery: DOS:
🩺 1. PAIN ASSESSMENT
🩺 PAIN ASSESSMENT TOOLS - SELECT ONE
Assessment Tool:
📊 NRS 0-10
0
No
Pain
1
2
3
4
Mild
5
Mod
6
7
8
9
10
Worst
0=No | 1-3=Mild | 4-5=Mod | 6-7=Sev | 8-10=Worst
😊 FACES Scale
😊
0
No
Hurt
🙂
2
Hurts
Little
😐
4
Hurts
More
😟
6
Hurts
Much
😢
8
Hurts
Lot
😭
10
Hurts
Worst
Best for: Pediatric patients (3+ years) • Language barriers • Cultural differences
📋 Pain Score Documentation
Current:
/10
Worst (24h):
/10
Best (24h):
/10
Average:
/10
Pain During: Rest Movement Both
Pattern: Constant Intermittent Breakthrough
📍 Pain Location & Characteristics
Location:
Pain Type/Quality:
FLACC Scale (For Non-Verbal / Pediatric Patients)
Category 0 Points 1 Point 2 Points Score
Face No expression / smile Grimace / frown Frequent grimace / clenched jaw
Legs Normal / relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quiet, normal Squirming, shifting Arched, rigid, jerking
Cry No cry (awake/asleep) Moans, whimpers Crying steadily, screams
Consolability Content, relaxed Reassured by touch/talk Difficult to console
TOTAL FLACC SCORE (0-10):
🏥 2. CLINICAL STATUS & FUNCTIONAL ASSESSMENT
💓 Vital Signs
BP: mmHg
HR: bpm
RR: /min
SpO₂: %
Temp: °C
🚶 Functional
Mobility: Indep
Assist
Bed
ADL: No limit
Limited
Sleep: Good
Fair
Poor
😴 Sedation
S=Sleep 1=Alert
2=Drowsy 3=Drifts
4=⚠️Notify
⚠️ Side Effects
N/V: None Mild Sev
Itch: None Mild Sev
Urine: OK Retention
Bowel: BM: Const
Current Pain Management Regimen
Medication Route Dose Freq Last Eff
G F P
G F P
G F P
G F P
🎯 3. APS INTERVENTIONS & ASSESSMENT
Regional Anesthesia Assessment
Type: None Epi PNB Spinal TAP
Site: Clean Intact Leak Red
Sensory: T-T Motor: 0 1 2 3
Infusion: Rate: (On Off)
PCA Assessment
Drug: Conc:
Basal: Bolus: Lockout:
24h: Att: Del: Ratio: G F P
Issues: None Pain Sedation
📋 4. PLAN & RECOMMENDATIONS
Today's Plan
Continue current regimen
Adjust doses:
Add med:
Regional: Cont Remove
PCA: Cont DC PO
DC med:
📚 Patient Education & Communication
Pain management expectations discussed
PCA/Epidural device use explained
Side effects & management reviewed
When to call for help explained
Patient/family questions answered
Patient Understanding: Good Fair Poor (Needs reinforcement)
📅 Follow-up & Monitoring
Next APS Visit: Tomorrow PRN
Discontinue APS
Monitor Freq: Q4h Q6h Q8h Other
⚠️ Notify APS if:
• Pain score > /10
• Sedation score ≥ 3
• RR < or SpO₂ < %
• Uncontrolled N/V
• Catheter site issues
🩺 5. NURSING DOCUMENTATION
Assessment & Interventions
Site Care: Dressing changed Assessed
Events: None Reported (Inc#: )
Interventions: Reposition Ice/Heat Relax
Comments:
📝 CLINICAL NOTES & OBSERVATIONS


✍️ PROFESSIONAL SIGN-OFF
APS Physician/Fellow
Name:
Lic#: Time:
APS Nurse
Name:
Date: Time:
Floor Nurse
Name:
Unit: Time:
Form F-11 | Acute Pain Service Daily Rounds | Version 1.0 | Page 2 of 2 | Medical Record - Permanent