Assessment & Plan Elements
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c/o [select name="Pain level" value="10|9|8|7|6|5|4|3|2|1|0"] out of 10 pain.
Pain type [checkbox value="acute pain|chronic pain|surgical pain|neuropathic pain|phantom pain|referred pain"]
Pain orientation[checkbox value="right|left|anterior|distal|inner|lower|mid|outer|posterior|proximal|upper|other"]
Pain location[select name="pain location" value="abdomen|ankle|arm|back|breast|buttocks|chest|coccyx|ear|elbow|epigastric|extremity|eye|face|flank|foot|generalized|groin|hand|head|hip|incision|jaw|knee|leg|mediastinum|mouth|neck|nose|perlvis|perineum|penis|pretibia|rib cage|rectum|sacrum|sclera|shoulder|scrotum|sternum|tibia|throat|teeth|umbilicus|uterine|vagina|wrist|"][checkbox value="pain radiating towards"][text size="10"
Pain descriptors[checkbox name="pain descriptors" value="aching|burning|cramping|crushing|discomfort|dull|headache|heaviness|itching|jabbing|nagging|numbness|penetrating|pins and needles|pounding|pressure|radiating|sharp|shooting|sore|spasm|squeezing|stabbing|tender|throbbing|tightness|tingling|tiring|unable to describe"]
Pain frequency[select name="Frequency" value="constant/continuous|rarely|once a week|several days a week|intermittent|"]
Pain onset[select name="Onset" value="awakened from sleep|gradual|ongoing|progressive|sudden|unable to tell"]
Pain aggravating factors[checkbox name="pain aggravating factors" value="bending|coughing/breathing|exercise|kneeling|reposition/movement|palpation/touch|squatting|standing|straightening|stretching|walking|"]
Resident's stated pain goal[select name="Goal" value="No pain|1|2|3|4|5|6|7|8|9|10|No pain - 0|Mild 1-3|Moderate 4-6|Severe 7-10|unable to assess r/t condition"]
Pain interventions[checkbox name="Pain interventions" value="Medication (see MAR)|heat applied|cold applied|compression|reposition|declines|MD notified (comment)|distraction|elevated|emotional support|environmental changes|food|massage|music|prayers|relaxation technique|rest||"]
c/o out of 10 pain.
Pain type
Pain orientation
Pain location
Pain frequency
Pain onset
Pain aggravating factors
Resident's stated pain goal
Pain interventions

Result - Copy and paste this output: