Six Tips to Documenting Patient Pain

We know you take good care of your patients. You know you take good care of your patients. But insurance companies reimbursing your claims don’t know how well you take care of your patients. It’s up to you to tell them.

What’s the best way to do this? A detailed assessment of the patient and the patient’s chief complaint during transportation. Part of this necessary assessment process is completely and accurately documenting the patient’s pain.

Following these tips when documenting patient pain does double duty by a) allowing the receiving facility to get a complete and accurate picture of the patient’s pain in order to give quality continued care, and b) increasing the likelihood of your claims getting paid by insurance companies.

Tip 1: Document the SEVERITY level of pain

On a scale of 1—10 (with 10 being the worst), how much pain does the patient report experiencing?

Tip 2: Document what causes VARIABILITY of pain

What increases the pain (movement, palpation, bearing weight, etc.) and what reduces the pain (ice, elevation, not moving the affected area, etc.)?

Tip 3: Document the MOVEMENTS of the patient at pain onset 

What was the patient doing at the onset of pain (e.g., mowing the lawn, climbing a ladder and fell down, sleeping and was awakened by pain, etc.)?

Tip 4: Document the LOCATION of pain 

What is the specific location of the pain? Be as specific as possible and include the laterality of the pain–which side of the body, and which specific body part is experiencing pain (e.g., pain is in the lower right arm, instead of just saying “arm pain”). Medicare and several other insurances require laterality when coding for insurance claims. If patient is experiencing abdomen pain symptoms, document which quadrant of the stomach the pain is located in (e.g., patient is experiencing pain in the lower left quadrant of the stomach).

Tip 5: Document the TIME of pain onset

What time or how long ago did the patient report the pain starting? Remember to be specific!

Tip 6: Document your EVALUATION of the pain site

What did you find at the pain site? Was there swelling, deformity, bruising, tenderness, etc.? Was the patient guarding the area of pain?

*Have any documentation questions? Email Grant Helferich, Omni EMS Billing‘s documentation expert.


Grant Helferich is employed as the EMS Advisor/Client Trainer with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator’s Society. He was certified as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked EMS for over 35 years in roles such as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.

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