Standards › Standard 3 › Policies
Policy · MNP-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 3.3
At a glance
- Every patient’s pain is assessed with a structured tool on admission.
- Pain is reassessed at a set interval and after any intervention for pain.
- The score is recorded and acted on.
- Pain that is not controlled is escalated to the responsible clinician.
- Stop and get help straight away if: a patient in pain is not assessed on admission, or uncontrolled pain is not escalated.
1. Purpose
To make sure pain is measured, treated and measured again, not asked about once (3.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Pain asked about once on admission is quickly forgotten. Assessing it with a structured tool, and again after treatments, shows whether the treatment is working and when it must change.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Owns the policy and audits it | Management |
| Ward nurse | Assesses, records and reassesses | Nurse |
| Responsible clinician | Reviews uncontrolled pain | Doctor |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Assess.
- Assess pain with the structured tool on admission (MNP-FRM-002).
- Record the score and the location.
Key point: A score, not a question.
Step 2. Reassess.
- Reassess at the set interval and 30 to 60 minutes after each pain intervention.
Key point: After treatment, check again.
Step 3. Act.
- Treat according to the plan, and escalate pain that is not controlled.
Key point: A score that does not fall is a problem.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Patients with pain score on admission | 100% | Monthly | Ward manager | Escalate to clinical director |
| Pain reassessed after intervention | At least 90% | Monthly | Ward manager | Escalate to clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| MNP-SOP-002 | Structured pain assessment and reassessment | Procedure |
| MNP-FRM-002 | Pain assessment chart | Chart |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on Ferreira-Valente et al. (2011) on validated pain intensity scales. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
No e-learning course is linked to this document yet.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)