When assessing pain with a numeric scale, what should you document besides the score?

• A. Location, quality, duration, and the numeric score.
• B. Only the numeric score.
• C. The medication given.
• D. The time pain started.

Answer: (B)

The essential idea is to capture a clear, objective measure of pain quickly and consistently. Recording the numeric pain rating gives the team a standard snapshot of the patient’s current pain level that can be tracked over time and used to judge response to interventions. In many CNA roles, you report that score exactly as the patient gives it and alert the nurse to any big changes. Other details like where the pain is, how it feels, how long it has lasted, or when it began are typically gathered and documented by the nurse in the broader assessment, or noted in separate records related to treatment. So, the most appropriate documentation beyond the score is simply the score itself, with a report of any notable changes.