The creators of this tool are loved ones with strong skill sets, but no current professional affiliation with care provision agencies.  Many studies in many settings are needed to give a tool like this “gold standard” traction.  The following is offered with all due respect to the medical professionals in hospitals, clinics, rehabilitation agencies, schools, and sheltered care settings.  Here are questions to facilitate “in house” quality assurance in regard to communication of an individual’s pain.  Our hope is to have some consistency in the core data set, enabling decisive meta-studies to be published at some near future date.  The studies should clarify this communication tool’s validity, reliability, and institutional cost impact in many settings around the world.

A second goal is to facilitate single subject studies, because there are many people with unique combinations of disorders needing scientific attention; and many advanced students in need of single subject studies to perfect their clinical and research skills.  We encourage therapeutic professionals in training to use the following in their data sets, as well.

Questions follow for admitting, start of new year, or change of personnel dealing primarily with this limited communicator.

Mark as many as apply:

Patients current age in Years___, Months___.

1.  How does patient express pain at home:  ____meets own needs without other’s help;

____tells caregiver with words like “ouch”, “pain,” “need meds,” _____cries; _____ faces shows appearance of distress; _____squirms, body actions; ____use of assisted communication device; and ____use of pain scale.  Use lines below to detail communication device history, and/or pain scale practice log, and/or other language or  method of communication:

Questions for release from facility, end of year, or end of primary personnel’s responsibility (filled out by personnel named and signed below):

1.  Patient’s communication of pain is:  ________clear and consistent, _________ adequate, _________inconsistent or questionable:  ________________________________________________________________________________________________.
2. If questionable or inconsistent, were facility operations effected?

____patient required more staff time to get needs met; ___patient’s reaction to pain resulted in personal or personnel injury; ____patient’s reaction to pain resulted in material waste; _____patient care was less than ideal.

3. If patient response was adequate, inconsistent or questionable:  what helped?


What hindered?  ________________________________________________________________________________________________

4.  Was a pain scale used________   Name of scale ____________________________________________

5.  Practice with scale prior to use with pain:  ____none, _____1-5 sessions, _____6-10 sessions _____ 11-20 sessions, ______21-36 sessions, _______37 or more sessions. _______unknown

6.  Family/caregivers were present and available during ________ percent of my (personnel’s) interaction with patient. (Estimate-100%, more than 75%, > 50%, less than 50%, < 25%, no).

7. ____percent of observed interactions family/caregivers appeared supportive of patient.

8. ____percent of observed interactions family/caregivers appeared supportive of treatment plan.


Signature_______________________________ Name ______________________________ Date __________

For an easy print version of this Recommended Data Standardization, please click here.