Pediatric Pain AIR Cycle Quarterly Report

(For data collection purposes only)

Date: Report for Year & Quarter:

NDNQI® Hospital Code: Number of Patients Surveyed:
Unit Name:

Patient #_________ Patient #_________ Patient #_________ Patient #_________ Patient #_________

Total Number of initial assessments

in the last 24 hours for this patient:
Patient Age* (For NICU, select months and/or days only)
Years: (between 1 & >21)
Months: (between 1 & 11)
Days: (between 1 & 30)
Patient Gender: (F/M)

Enter the first two pain cycles of the 24

hour period for this patient below:
Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2
Presence of Pain:*
Pain Scale:*
Type of Pain:*
Intervened?:* (Y/N)
Type of Intervention:*
(enter all codes that apply)
Reassessed after intervention? (Y/N)*

Patient #_________ Patient #_________ Patient #_________ Patient #_________ Patient #_________

Total Number of initial assessments i

Patient Age* (For NICU, select months and/or days only)
Years: (between 1 & >21)
Months: (between 1 & 11)
Days: (between 1 & 30)
Patient Gender: (F/M)

Enter the first two pain cycles of the 24

hour period for this patient below:
Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2 Pain Cycle #1 Pain Cycle #2
Presence of Pain:*
Pain Scale:*
Type of Pain:*
Intervened?:* (Y/N)
Type of Intervention:*
(enter all codes that apply)
Reassessed after intervention? (Y/N)*

*
Required fields Presence of Pain Pain Scale Codes Type of Intervention Codes
Type of Pain Codes
1=FACES 7=N-PASS 1=Procedural/Post procedural 1=Pharmacologic
Codes 2=FLACC 8=NIPS 2=Post operative 2=Distraction
3=Numeric Scal 9=Behavorial cues 3=Chronic 3=Relaxation
Pain 4=Oucher Scale 10=Physiologic cues 4=Traumatatic 4=Music
5=Visual Analog 11=Other 5=Acute disease process 5=Repositioning
6=CRIES 6=Developmental 6=Environmental Modification
No Pain 8=Other 7=Other
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