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Discussion

Pain assesment

Does the pain assesment need to be on the intra operative OR record?I know they do the pain assesment in recovery room how about before the patient goes to sleep? Should it be on the intraop record.

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We don't document pain on our OR record. Preop gets a baseline and records it in their documentation.

We don't document on our OR record either. The CRNA asks them if they're having any pain when they wake up in the OR. Don't know if they're documenting the patient's response. They're usually still pretty out of it so they're not asking them to rate they're pain, just whether or not they're having any.

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