When documenting pain, what should be included in the report?

Including details provided by the patient about the pain is essential in documentation because it captures the subjective experience of the patient. This information often includes the location, intensity, duration, and characteristics of the pain, which are critical for understanding the patient's condition and tailoring their treatment. By obtaining and documenting the patient's own description, healthcare providers can gain insights into the pain's impact on the patient's daily life and can make more informed clinical decisions regarding pain management.

Other options, while relevant in certain contexts of patient care, do not directly address the specific aspects necessary for accurately documenting pain. For instance, the patient's medical history provides valuable background but does not focus on the current pain experience. The time of medication administration is crucial for tracking treatment responses, but it doesn’t describe the pain itself. Lastly, the nurse's opinion may inform the care plan, but it is inherently subjective and may not reflect the patient's actual pain experience. Therefore, the most pertinent information for documenting pain is the details that the patient shares.