Pediatric Pain Scale Age-Appropriate Use Audit

Audit template to verify that pediatric pain scales are selected according to patient age and developmental status, and that pain assessments are documented in a timely manner.

Audit Details

• Patient age documented in the record
  Record the patient age in months or years as documented in the chart.
• Developmental status documented or clearly inferable
  Determine whether the chart includes developmental status, verbal ability, or another basis for selecting a pain scale.
• Encounter type identified
  Select the encounter setting reviewed.
• Pain assessment event reviewed
  Document the date and time of the pain assessment being audited.

Age-Appropriate Pain Scale Selection

• Pain scale selected is appropriate for age and developmental status
  Confirm the documented scale is appropriate for the patient’s age and developmental level. Use observational tools such as FLACC for younger or nonverbal children and self-report tools such as Wong-Baker FACES when the child can reliably self-report.
• FLACC used when indicated
  If the patient is an infant, toddler, preschool-age child, or otherwise unable to reliably self-report, verify that FLACC or another observational scale was used when appropriate.
• Wong-Baker FACES used when indicated
  If the patient is developmentally able to self-report pain, verify that Wong-Baker FACES or another age-appropriate self-report tool was used when appropriate.
• Pain scale documented by name
  The chart should identify the pain tool used by name, not just record a pain score.
• Pain score recorded in the expected format
  Verify the score is documented in the correct format for the selected tool, such as FLACC component-based scoring or a Wong-Baker face score.

Documentation Timeliness

• Initial pain assessment documented promptly
  Measure the elapsed time between the clinical event requiring assessment and the documented initial pain score.
• Pain reassessment documented after intervention
  Measure the elapsed time between pain intervention and reassessment documentation.
• Documentation includes date and time stamps
  Verify that pain assessment entries include date and time stamps sufficient to establish timeliness.
• Pain reassessment interval aligns with facility policy
  Confirm the reassessment interval documented in the chart aligns with the facility policy or order set.

Clinical Documentation Quality

• Pain score and scale are consistent throughout the record
  Verify the documented scale and score remain consistent across notes, flowsheets, and medication records.
• Behavioral cues or patient report support the selected scale
  Confirm the chart contains supporting observations or patient statements that justify the selected pain tool.
• Documentation includes response to pain intervention
  Verify the record shows whether the intervention improved the patient’s pain score or symptoms.
• Any mismatch between age/development and scale is explained
  If a nonstandard scale was used, confirm the chart includes a clear clinical rationale.