Academy of Chiropractic’s Doctors PI Program

Narratives #72

From the Desk of :

“Utilization of Pain Scales – circa 2018”

SAVE TIME & Increase accuracy in documentation

Pain scales are a critical criteria in understanding both the continuum of care and the subjective history in response to care for your patients. Although there are numerous tools and clinical signs to objectify pain, the listing of a pain scale is considered usual and customary across professions.


Noble, Clark, Meldrum, Have, Seymour, Winslow and Paz (2005) reported:

     Three strands of activity can be identified in the history of pain measurement. The first, psychophysics, dates back to the nineteenth century and measures the effect of analgesia by quantifying the noxious stimulation required to elicit pain, as well as the maximum stimulation tolerated. The second uses standardized questionnaires for patients, developed to categorize pain according to its emotional impact, distribution, character, and other dimensions. The third asks patients to report on pain intensity using rating scales and is used in clinical trials where analgesics are evaluated and results can be combined to influence clinical guidelines and protocols. Although all three strands have found a place in modern clinical practice or drug development, it is the rep good morning sorting of pain by patients undergoing treatment using simple scales of intensity which has emerged as the crucial method by which analgesic therapies can now be evaluated and compared. J Pain Symptom Manage 2005;29:14–21


Olson (2018) wrote:

     Over the past 30 years, we have seen tremendous changes in the diagnosis and treatment of pain—including a better understanding of pain as the 5th vital sign. The prevalence of pain is striking. According to the Institute of Medicine’s survey, an estimated 100 million people in the US experience pain.1 Further, 25% of adult Americans report having an episode of pain during the last month that persisted for more than 1 day. Data from the National Health Survey indicated that within the sample, 15% of adults had experienced migraines or severe headache, 15% experienced pain in the neck, 27% in the lower back, and 4% in the jaw. According to a recent article by Turk and Melzack, despite improvements in medicine, “pain is not well understood, and the severity of the pain may not be adequately managed.”4 They further note that the central problem in providing appropriate treatment of pain continues to be the inherent subjectivity of the pain experience.


I urge you to read the complete article about by Olson as it illuminates pain from a historical perspective and if you click on the reference above you will find the entire article. It is important to understand pain from as many perspectives as possible as it is integral in reporting both the severity of the injuries of your patients and the efficacy of your care.



When reporting the subjective response on a daily basis, centralization is much more critical to the reporting of your care and the patient’s current condition than simply a numerical number. In the past, it was held that reporting pain on a day-to-day basis was critical in following the continuum of care and over the last few years we’ve gone away from understanding the overall condition of the patient versus what is happening joint by joint and region by region. Centralization refers to not just the immediate or primary pain but all of the issues that the patient experiences. That is why we use the OPQRST method in reporting the total condition of the patient.


The “P” is about pain, however not just a numerical scale but the quantitative response of that pain to the person as a whole. Pain scales are important and critical to both a legal case and understanding the continuum of care of your patient. However, by reporting pain scales on a visit to visit basis you often do not capture the true condition or response of that patient as a whole. Therefore on your SOAP notes it is strongly suggested that you simply write the patient is feeling the same as the last visit, better than the last visit or worse than the last visit understanding that rehabilitation has ebbs and flows.


These ebbs and flows indicate that patients will feel a little better and a little worse on a visit to visit basis, but over time they should be “spiraling upwards” in both feeling better with increased overall function. It is therefore strongly recommended that you reserve pain scales for your initial evaluation and your reevaluations every 30 days so that the patient has an opportunity to go through those ebbs and flows or ups and downs and you get a clear “snapshot” of the efficacy of your care as well as the subjective condition of your patient during the reevaluations.


Please understand that the goal is to report subjective response in conjunction with function and that goes well beyond pain scales. A prime example is a pianist who initially reported a pain scale of three in their right middle finger but can no longer be a concert pianist due to that pain. A plumber can recruit his nine other fingers and perform his task uninterrupted with the same pain scale. Therefore, you must continually relate subjectivity and functionality versus simply a pain scale in determining the current condition and functional abilities of your patients.


I know I am intertwining the subjectivity of pain scales and function, however it is inaccurate and irresponsible on a provider’s part to “pigeonhole” the patient and characterize their subjectivity purely based upon a numerical number.


The other side of the coin is the medical – legal aspect of the reporting of the patient subjectivity. Every lawyer in the country will “live and die” with those pain scales because the courts mandate that there is a narrow level of reporting pain. Therefore you must be more descriptive in reporting the functionality of your patient in the “S” part of your SOAP note and not just report saying better or worse as last visit and add functionality limitations on a daily basis (when applicable) in your notes.




The AND is a critical component of your reporting. We had previously trained you to report that “Mrs. Jones was in a car accident AND can no longer lift groceries where she previously could prior to the injury.” This AND could be considered in your daily soap notes. When you are reporting that the patient felt the same, better or worse you should consider writing AND to relate how the patient’s function has persistently been negatively affected or is getting better. However, be very careful not to be overzealous and overreport in wanting to show how great your care is and leave the impression that the patient’s limitations are resolved, when we all know like pain scales that ebb and flow, so does functionality. An over-exuberant report can destroy a legal case, where underreporting can destroy your reputation if other providers do not concur.


If you choose to limit your AND to evaluations and reevaluations and solely use the “same, better or worse as last visit” in your daily SOAP notes, that is perfectly acceptable, but you then must be VERY diligent in clearly explaining the changes between reevaluations and include pain scales on each body part involved.


Ideally, the subjective response from your patient should look like a stock market graph where there are constant minor corrections, but the overall trend spirals upwards. The only caveat is that you never know where the top of the chart is and in our world that is called MMI and is purely a clinical decision. The following chart is a sample in the financial world that will help you visualize what you need to create in words in both your evaluations, reevaluations and SOAP notes.