shift is wild

How a note is read

Charting pain when your patient can't give you a number

A behavioral pain score only helps if the note says what you saw. How to chart FLACC, CPOT and PAINAD so every dose has proof it worked.

8 min read built on 2 full opinions updated 2026-09-26

Written by a med-surg RN, ten years, day shift. Why there is no name on it

Maya reacting to this topic

Your patient can't rate their pain. Maybe it's a toddler after surgery. Maybe it's an intubated patient on a fentanyl drip, or a resident with advanced dementia who keeps pulling at a dressing. You still have to assess the pain, treat it, and show the treatment worked. A blank pain field does none of that. A behavioral scale does, if your note says what you actually saw.

The short version

  • Try self-report first. Every time. A patient with mild dementia may still point to a faces card. A child may nod yes or no. Go to a behavioral scale only when self-report fails, and write down why.
  • Match the scale to the patient and the unit. FLACC for young children and other patients who can't talk. CPOT for critically ill and ventilated adults, or BPS if that's what your unit uses. PAINAD for advanced dementia. One tool per patient. Don't switch from shift to shift.
  • Chart the behaviors, not just the total. CPOT 5 tells the next reader almost nothing. Grimacing, guarding R flank, fighting vent, CPOT 5 tells them what you saw.
  • Tie every dose to a reassessment on the same scale. Score before the dose. Dose and time. Score after, with the time. Then what you did next. That sequence is your proof the pain got treated.
  • Chart what else could explain the behavior. Agitation can be a full bladder, hypoxia, delirium or fear. Write down what you ruled out.

What goes wrong

Mistake number one: a number with nothing behind it.

A FLACC of 6 or a PAINAD of 4 is a sum of item scores. Chart only the total and the next reader can't tell:

  • which behaviors you saw (a grimace or a moan? restlessness or a rigid body?)
  • whether the next nurse scored the same behaviors, or the score dropped because the patient finally fell asleep
  • whether the post-dose score measured the same pain or something else

Mistake number two: the dose and the reassessment come apart. The pre-dose score is in the flowsheet. The dose is in the MAR. The post-dose score is missing, or it shows up three hours later on another scale. Now nobody can show the drug did anything. A 0 at 0400 doesn't prove the 2200 dose worked.

Mistake number three: treating the scale like a severity dial. CPOT and PAINAD were built mainly to detect pain, not to measure it precisely. A CPOT of 6 isn't twice the pain of a CPOT of 3. So describe what changed after the dose: the grimace resolved, the patient stopped fighting the vent, the resident let you reposition her. That carries more weight than the number alone.

Mistake number four: a behavioral score on a patient who could have answered. If the patient can say yes it hurts or point to a face, that answer comes first.

It is not hypothetical

Four J's Community Living Center, Inc. v. Wagner, Texas Court of Appeals, 1st District (Houston), 2021 https://www.courtlistener.com/opinion/4885472/four-js-community-living-center-inc-and-anthonia-uduma-v-patti-j/

This isn't a nursing negligence case. It's about a fire at a residential care facility. The injured resident was blind, had cerebral palsy and a profound intellectual disability, and could answer only in one or two words. The defense argued the evidence didn't support the jury's award for her physical pain. The court affirmed.

Why it matters for charting: what the opinion says about her hospital records. They describe her burns, debridement and skin grafts. And they state that:

“The hospital staff could not assess Jenny’s pain using the pain scale”

because she was nonverbal. Most of the pain evidence the opinion goes on to describe came from her mother's testimony. After extubation, for example, her mother heard her grinding her teeth and took that to mean she was hurting.

Here's the point for us. Years later, in a courtroom, someone read that chart to find out how much pain this patient had been in. And what the chart could say came down largely to this: the numeric scale couldn't be used. A behavioral scale with the behaviors written out would have given that reader your own direct observations.

What to write instead

Pediatric post-op, FLACC

How it often gets charted Better
Pain: FLACC 7. Morphine given.1410 FLACC 7 (F2 grimace/quivering chin, L2 kicking, A1 squirming, C1 intermittent crying, C1 consoled by parent's touch). Surgical site dressing dry. Morphine 0.05 mg/kg IV = 1 mg given 1415 per order.
Pt resting comfortably.1445 FLACC 1 (F1 occasional frown, L0, A0, C0, C0). Asleep on mother's lap, face relaxed, legs still. RR 22.
Crying, parents at bedside.Crying started after parents left the room at 1600; stops when held; face relaxed, legs relaxed. FLACC 2. Distress appears separation-related; no analgesic given; will reassess in 30 min.

Ventilated adult, CPOT

How it often gets charted Better
CPOT 5, agitated, bolus given.0210 CPOT 5: facial 2 (grimacing, eyelids tight), body 1 (touching ETT), muscle tension 1 (resists passive arm flexion), vent 1 (coughing, intermittent high-pressure alarms). RASS +1. SpO2 96%, suction yields scant secretions. Fentanyl 25 mcg IV bolus given 0215 per order; drip unchanged at 50 mcg/hr.
Pain controlled.0245 CPOT 1: facial 0, body 0, tension 1, vent 0. No further alarms. RASS 0. HR 112 → 94.
Drip titrated up for comfort.0300 Fentanyl increased 50 → 75 mcg/hr per titration order for CPOT 4 (grimace 2, restless 1, resisting vent 1) persisting after bolus. Reassess at 0400 per protocol.

Advanced dementia, PAINAD

How it often gets charted Better
Resident agitated, yelling out.0930 PAINAD 6: breathing 1 (labored), vocalization 2 (repeated calling out, moaning with movement), face 1 (frowning), body 1 (guarding L hip), consolability 1 (distracted by voice briefly). Unable to rate pain; did not respond to faces card. Brief voided, no signs of UTI documented today.
Tylenol given, resident calmer.Acetaminophen 650 mg PO given 0940 per order. 1040 PAINAD 1 (face 1 occasional frown). Allowed repositioning and AM care without calling out. Sat in chair 20 min.
Denies pain.Resident said no when asked about pain but grimaced and pulled L leg away during transfer. PAINAD 4 during movement, 0 at rest. Reported to charge RN for evaluation of L hip.

Words that do the damage

Word or phrase Why it hurts What to write instead
resting comfortablyA conclusion with no observation behind itThe behaviors: face relaxed, RR 16, no guarding, sleeping
pain controlledSays nothing about what controlled means for this patientPost-dose score with the time and what changed
agitatedCould be pain, delirium, hypoxia or a full bladderThe specific behavior, plus what you ruled out
tolerated wellHides what you actually sawTolerated repositioning without grimace or vocalization
unable to assessUsually not true. You can always score behaviorUnable to self-report; FLACC / CPOT / PAINAD used
pt denies pain (alone)With dementia or delirium, a no may not be reliableThe words plus the behavior, especially during movement
A bare CPOT 5A total alone can't be compared or checkedThe item breakdown in parentheses

What the guidance says

  • If the patient can self-report, use self-report and add behavioral observation on top. If they can't, switch to a behavioral scale and chart why. (WA DSHS, NurseChartingPro)
  • FLACC scores five behaviors (face, legs, activity, cry, consolability) at 0 to 2 each. Total: 0 to 10. (WA DSHS, Nursing Fundamentals 2e)
  • PAINAD is the behavioral tool for advanced dementia. It scores breathing, vocalization, facial expression, body language and consolability, 0 to 2 each. (NurseChartingPro, Mid South Pain)
  • Sedated or intubated patients need a behavioral tool. FLACC is for children and cognitively impaired patients who can't talk. CPOT is for the critically ill. (ScienceInsights, NursingSchoolsNearMe)

Copy this

Pre-dose assessment

`` [TIME] Pain assessment. Patient unable to self-report: [REASON — e.g., intubated / age 18 months / advanced dementia, did not respond to faces card]. Scale: [FLACC / CPOT / PAINAD]. Total [SCORE]. Items: [ITEM 1] [SCORE] ([BEHAVIOR SEEN]), [ITEM 2] [SCORE] ([BEHAVIOR SEEN]), [ITEM 3] [SCORE] ([BEHAVIOR SEEN]), [ITEM 4] [SCORE] ([BEHAVIOR SEEN]), [ITEM 5 IF APPLICABLE] [SCORE] ([BEHAVIOR SEEN]). Other causes checked: [e.g., SpO2 __%, suctioned, brief checked, positioned, parent present]. Findings: [FINDINGS]. Vitals: HR [ ], BP [ ], RR [ ], SpO2 [ ]. RASS [ ] if applicable. ``

Dose and reassessment

`` [TIME] [DRUG] [DOSE] [ROUTE] given per order for [SCALE] [SCORE]. [TIME] Reassessment, same scale: [SCALE] [SCORE]. Items: [ITEM] [SCORE] ([BEHAVIOR]), [ITEM] [SCORE] ([BEHAVIOR]), [ITEM] [SCORE] ([BEHAVIOR]), [ITEM] [SCORE] ([BEHAVIOR]), [ITEM] [SCORE] ([BEHAVIOR]). Change observed: [e.g., grimace resolved, stopped resisting vent, allowed repositioning without moaning]. Vitals: HR [ ], BP [ ], RR [ ], SpO2 [ ]. RASS [ ] if applicable. Plan: [e.g., continue current regimen / next reassessment at TIME / see escalation note below]. ``

Pain persists after treatment (note and provider message)

`` [TIME] [SCALE] remains [SCORE] at reassessment [MINUTES] min after [DRUG DOSE ROUTE] given at [TIME]. Persistent behaviors: [BEHAVIORS]. Non-drug measures tried: [e.g., repositioned, splinted incision, parent holding, dimmed lights]. Response: [RESPONSE]. [PROVIDER NAME] notified at [TIME] by [PHONE / PAGE / IN PERSON]. Reported: [SCALE] trend [SCORE] -> [SCORE], behaviors [BEHAVIORS], vitals [VITALS], meds given [MEDS AND TIMES]. New orders: [ORDERS / NONE]. Implemented at [TIME]. Next reassessment at [TIME]. ``

If you remember one thing

Chart the behaviors, not just the score. And every dose gets a score before and a score after, on the same scale, with the times.

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

How would you chart it?

This is the part we cannot research. If you have a way of writing this that has held up — put it here. No account, no name needed. Nothing that could identify a patient: no room numbers, no dates of birth, no MRNs. Use placeholders, the example still works.

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