Information Specification

User Interface Name

Field Identifier

Definition

Data Value Format (code or other value)

Value Sets

Date of Assessment

 

Assessment_Date

 

This is the date the actual assessment was carried out with the patient

 

8 digit numeric, CCYYMMDD
6 digit numeric: hh:mm:ss

 

 

Is your patient able to verbalise their pain?

 

Verbalise_pain

 

This is to indicate whether the patient is able to verbalise their pain

 

n1

1 Yes

2 No

Pain Assessment Tool Used

 

Pain_tool

 

This is to indicate what pain assessment tool has been used

 

n1

1 - Categorical (N-M-M-S)
2 - Numerical
3 - Pain AD
4 - Adapted Abbey

Categorical Scale

 

Categorical_scale

This is to indicate the patients categorical pain scale

 

n1

0 No Pain
1 Mild Pain
2 Moderate Pain
3 Severe Pain

Action / Comments

 

Action_comments_categorical

 

This is to provide a comment or detail the actions taken

 

Free Text

 

Numerical Rating Scale Score

 

Numerical_score

 

This is to indicate the patient numerical rating scale score

 

n1

1

2

3

4

5

6

7

8

9

10

Equivalent Categorical Scale

 

Equiv_cat_scale_numerical

 

This is to indicate what the equivalent categorical scale is against the numerical scale

 

n1

0 No Pain
1-3 Mild Pain
4-6 Moderate Pain
7-10 Severe Pain

Action / Comments

 

Action_comments_numerical

 

This is to provide a comment or detail the actions taken

 

Free Text

 

Pain AD Breathing
Independent of Vocalization

 

PainAD_Breathing

 

This is to indicate how the patient is currently breathing

 

An2

B1 - Normal
B2 -Occasional laboured breathing. Short period of hypervention
B3 - Noisy laboured breathing. Long period of hypervention. Cheyne-stokes respirations

 

Pain AD Negative Vocalization

 

PainAD_Negative_Vocalization

 

This is to indicate whether the patient has negative vocalization

 

An2

V1 - None
V2 - Occasional moan or groan. Low level speech with a negative or disappointing quality
V3 - Repeated Troubled calling out. Loud moaning or groaning. Crying

 

Pain AD Facial Expression

 

PainAD_Facial_Expression

 

This is to indicate how the patients facial expressions are

 

An2

F1 - Smiling or inexpressive
F2 - Sad. Frightened. Frown
F3 - Facial grimacing

 

Pain AD Body Language

 

PainAD_Body_Language

 

This is to indicate the patients body language

 

An2

L1 - Relaxed
L2 - Tense. Distressed pacing. Fidgeting
L3- Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out

 

Pain AD Consolability

 

PainAD_Consolability

 

This is to indicate the patients consolability

 

An2

C1 - No need to console
C2 - Distracted or reassured by voice or touch
C3 - Unable to console, distract or reassure

 

PainAD Scale Total Score

 

Painad_Scale_Totalscore

 

This is to indicate the patients total score on the PainAd scale

 

n1

0
1-3
4-6
7-10

 

Equivalent Categorical Scale

 

Equiv_cat_scale_PainAD

 

This is to indicate what the equivalent categorical scale is against the PainAD scale

 

n1

0 No Pain
1-3 Mild Pain
4-6 Moderate Pain
7-10 Severe Pain

 

Action / Comments

 

Action_comments_painad

 

This is to provide a comment or detail the actions taken

 

Free Text

 

Abbey Vocalisation e.g. whimpering, groaning, crying

 

Abbey_vocalisation

 

This is to indicate the patients vocalisation

 

8char

 

Absent
Mild
Moderate
Severe

 

Abbey Facial Expression e.g. grimacing, frowning, lookeing tense, looking frightened

 

Abbery_facial_expression

 

This is to indicate the patients facial expression

 

8char

 

Absent
Mild
Moderate
Severe

 

Abbey Change in Body Language e.g. fidgeting, rocking, guarding of body, withdrawn

 

Abbey_change_in_body_language

 

This is to indicate the patients change in body language

 

8char

Absent
Mild
Moderate
Severe

 

Abbey Behavioural Change e.g. alterations in usual patterns, increased confusion, refusing to eat

 

Abbey_behavioural_change

 

This is to indicate the patients behavioural change

 

8char

Absent
Mild
Moderate
Severe

 

Abbey Physiological Change e.g. temperature, rapid pulse, blood pressure outside normal limits

 

Abbey_physiological_change

 

This is to indicate the patients physiological change

 

8char

Absent
Mild
Moderate
Severe

 

Abbey Physical Changes e.g. skin tears, pressure areas, arthritis, contractures

 

Abbey_physical_changes

 

This is to indicate the patients physical changes

 

8char

Absent
Mild
Moderate
Severe

 

Equivalent Categorical Scale

 

Equiv_cat_scale_abbey

 

This is to indicate what the equivalent categorical scale is against the Adapted Abbey scale

 

n1

0 No Pain
1-3 Mild Pain
4-6 Moderate Pain
7-10 Severe Pain

 

Action / Comments

 

Action_comments_abbey

 

This is to provide a comment or detail the actions taken

 

Free Text

 

Frequency of Pain Assessment and Analgesia Administration

 

Assessment_frequency_analgelsia_admin

 

This is to indicate the recommended frequency of the assessment and analgesia administration

 

n1

1 - No pain - Reassess 12 hourly as per NEWS observations
2 - Mild Pain - Reassess 4 hourly
3 - Moderate Pain - Give analgesia, reassess after 30 - 60 minutes, ongoing assessment minimum 4 hourly
4 - Severe Pain - Give step 3 analgesia, reassess after 30 minutes