By Miranda Niemas, Nursing Student (BSN candidate)

This guide is currently pending review by a licensed registered nurse.

Last updated: October 13, 2026

FLACC Pain Scale: Nursing Guide for Nonverbal Pain Assessment

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My first FLACC score was wrong because I gave a post-op 4 year old a 2/10 after he told me he was fine. He was nonverbal from emergence delirium, not pain-free, and his legs were drawn up while he whimpered. FLACC is what saves you from a patient who cannot self-report but is clearly not comfortable. This guide breaks down each of the five categories, what each score actually looks like at the bedside, and how to document the result so the next nurse knows what changed.

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Why This Matters

Regulatory bodies: American Academy of Pediatrics (AAP) - Pediatric Pain Management, The Joint Commission - Pain Assessment and Management Standards, International Association for the Study of Pain (IASP) - Pain Assessment in Nonverbal Patients, CMS Hospital Conditions of Participation - Pain Management

The Joint Commission requires that every hospitalized patient has a pain assessment performed using a validated tool, and that the tool is appropriate to the patient. A numeric 0-10 self-report scale is not appropriate for a 6-month-old, an intubated adult, or a patient with advanced dementia, and using one anyway produces documentation that looks clean but does not reflect the patient. FLACC fills that gap for pediatric patients ages 2 months to 7 years and is widely applied (via the revised FLACC) to cognitively impaired adults and children. The scale was developed and validated at the University of Michigan by Merkel and colleagues in 1997, with strong inter-rater reliability when raters are trained. From a documentation standpoint, FLACC scores drive PRN analgesic decisions and intervention reassessments. They also build the audit trail showing pain was assessed at required intervals. Missing or mismatched pain scores (for example, a numeric self-report on a sedated child) are a common finding in chart review and a common basis for parental complaints about postoperative pain control.
  1. The FLACC: a behavioral scale for scoring postoperative pain in young children — Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. Pediatr Nurs. 1997;23(3):293-297 (1997)
  2. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment — Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. Paediatr Anaesth. 2006;16(3):258-265 (2006)
  3. R3 Report Issue 11: Pain Assessment and Management Standards for Hospitals — The Joint Commission (2017)
  4. Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System — American Academy of Pediatrics (AAP) (2017)

What the FLACC pain scale is and when to use it

FLACC stands for Face, Legs, Activity, Cry, Consolability. Each category gets scored 0, 1, or 2 based on observed behavior during a 1 to 5 minute assessment period, for a total pain score of 0 to 10. Merkel and colleagues developed the scale in 1997 at the University of Michigan to measure postoperative pain in preverbal children, and it has since been validated for any patient who cannot reliably self-report: pediatric patients ages 2 months to 7 years, patients emerging from anesthesia, intubated or sedated adults, and adults with advanced dementia or cognitive impairment (via the revised FLACC). If your patient can point to the Wong-Baker faces, speak a number on the 0-10 scale, or describe their pain in their own words, use a self-report tool first and document why you chose a behavioral tool if you choose one anyway. FLACC is the fallback when self-report is not available, not the default for every patient. One important note: FLACC is not the same instrument as CPOT (Critical-Care Pain Observation Tool) or BPS (Behavioral Pain Scale). CPOT and BPS are designed for adult ICU patients who are intubated and sedated, and they score different behavioral domains. A nurse on a med-surg or pediatric unit will most often use FLACC; a nurse in the adult ICU will most often use CPOT or BPS. See the section below for how to choose between them.

The five scoring categories

What each score looks like at the bedside, with the specific behaviors that distinguish 0, 1, and 2.

F - Face (0-2)

Score 0 for no particular expression or a smile. Score 1 for an occasional grimace or frown, a withdrawn or disinterested look, or a flat affect that was not present at baseline. Score 2 for a frequent to constant frown, a clenched jaw, or a quivering chin. The common error is scoring 0 on a sleeping child; a child who is asleep because of exhaustion from pain often has a furrowed brow and a tense face. Look at the baseline photo on the admission sheet if you have one, and compare. A face score of 2 in a nonverbal child is a red flag that should trigger an intervention and reassessment, not a "this is probably fine" shrug.

L - Legs (0-2)

Score 0 for a normal position or relaxed legs. Score 1 for uneasy, restless, or tense legs - the patient is not kicking, but the leg muscles are visibly tight and shift position often. Score 2 for kicking or legs drawn up toward the abdomen, which is a classic pain-guarding posture for abdominal or pelvic pain. In a post-op patient with a lower extremity incision or cast, drawing the legs up may not be possible; in that case a Legs score of 2 can manifest as visibly clenched thighs or an unbroken inability to relax the lower limbs. Document what you actually saw rather than defaulting to a middle score because the behavior did not fit the prototype.

A - Activity (0-2)

Score 0 for lying quietly, a normal position, or moving easily. Score 1 for squirming, shifting back and forth, or tense - the patient is not thrashing, but they cannot settle. Score 2 for an arched back, rigid body, or jerking movements. An arched-back score of 2 in an infant is an important sign that should prompt a careful reassessment for intra-abdominal pain, meningismus, or severe discomfort. Do not confuse jerking from a febrile seizure or a post-anesthetic shiver with Activity score 2; those are different clinical findings and are documented separately.

C - Cry (0-2)

Score 0 for no cry, whether awake or asleep. Score 1 for moans, whimpers, or occasional complaints. Score 2 for crying steadily, screaming, sobbing, or frequent complaints. In a cognitively impaired adult who is nonverbal, Cry score 1 may present as a verbal moan on repositioning and score 2 as steady vocalization. The Cry category is one of the most visible to family members at the bedside; a score of 2 with a parent in the room often becomes a parent complaint about pain control if the nurse does not visibly respond with an intervention and a reassessment.

C - Consolability (0-2)

Score 0 for content and relaxed. Score 1 for reassured by occasional touching, hugging, or being talked to - the patient is distractible and calms with nursing presence or a caregiver. Score 2 for difficult to console or comfort, meaning the patient remains distressed despite reasonable comfort attempts. Consolability is the category student nurses most often score incorrectly because it requires trying comfort measures first and observing the response. Walking into a room, watching for 30 seconds, and scoring a 0 without actually attempting to console is not an assessment; it is an assumption. If Consolability scores 2, that by itself usually drives a total FLACC of at least 4 and should trigger a medication review.

How nurses document a FLACC score

The score is the easy part. Documenting it in a way that drives clinical action is the part that matters.

Chart the individual category scores, not just the total. A total of 4 with Face 2 and Legs 2 is a different clinical picture than a total of 4 with Cry 2 and Consolability 2, and the oncoming nurse needs the category breakdown to know what to watch for. Document the time the assessment occurred, the observation period (for example, "5-minute observation"), the total score, the intervention given in response to the score (if any), and a reassessment score within 30 to 60 minutes of a PRN analgesic (the exact window is set by your facility policy). For a score of 0-3, continue scheduled reassessments at unit standard intervals. For 4-6, review scheduled and PRN pain orders, consider an intervention, and reassess within the PRN-appropriate window. For 7-10, notify the provider, give an available PRN, and reassess within 15-30 minutes - this is a pain emergency in a nonverbal patient and the chart should reflect escalation. A legally defensible FLACC entry looks like: time, category scores, total, intervention, reassessment score, reassessment time. Abbreviated entries that read only "FLACC 6" without any of the supporting elements are the pattern plaintiff attorneys flag in postoperative pain cases.

FLACC vs CPOT vs BPS and the 0-10 numeric scale

Picking the right tool for your patient is more important than picking one you already know.

Self-report (0-10 numeric or Wong-Baker) first

If the patient can point or answer, use a self-report tool. The patient is the most reliable source of pain intensity, and the numeric 0-10 scale or the Wong-Baker faces scale carries more validity than any observational tool. FLACC is a fallback, not a first choice.

FLACC for pediatric and cognitively impaired patients

Use FLACC for children ages 2 months to 7 years, for older cognitively impaired children (via the revised FLACC), and for adults with advanced dementia or nonverbal cognitive impairment. The five categories are simple to observe at the bedside and do not require specialized training beyond the scoring rubric.

CPOT for adult ICU patients

CPOT (Critical-Care Pain Observation Tool) is the preferred behavioral scale for intubated and sedated adult ICU patients. It scores facial expression, body movements, muscle tension, and compliance with the ventilator, with a total range of 0-8. A CPOT score of 3 or higher indicates pain in a sedated adult. Many ICUs pair CPOT with RASS to track sedation and pain together.

BPS for intubated adults without facial observation

BPS (Behavioral Pain Scale) is a 3-item adult ICU tool scoring facial expression, upper limbs, and compliance with ventilation, total range 3-12. BPS and CPOT measure the same construct and are comparable; facilities typically adopt one or the other. BPS is shorter than CPOT and is occasionally preferred when facial expression is partially occluded.

FLACC in NurseChartingPro

NurseChartingPro captures FLACC as a selectable option inside the pain block of the Skin and Wound category, alongside CPOT and BPS. When you score a wound-associated pain assessment for a nonverbal or cognitively impaired patient, you tap the FLACC chip, enter the total, and the structured field flows into the narrative the app generates at end of assessment. Because the behavioral scale selection and the score both live in structured fields, the narrative never mixes the FLACC score with a 0-10 self-report - a common charting error when a nurse uses a free-text field. If your facility requires the category breakdown (Face, Legs, Activity, Cry, Consolability) documented separately rather than only the total, add that detail to the notes section of the pain assessment.

Common Mistakes

Using FLACC on a patient who can self-report

Weak: A cooperative 10 year old post-appendectomy patient reports "it hurts a lot right here," but the nurse documents a FLACC score of 4 because FLACC is the default on the unit.
Strong: The same patient reports 7/10 on the numeric scale. The nurse documents a self-report score of 7/10, not a FLACC. FLACC is reserved for patients who cannot reliably self-report.

Self-report is the gold standard for pain intensity. Using a behavioral tool on a patient who can speak their pain undercuts the validity of the assessment and creates a score that does not reflect the actual patient experience.

Scoring only the total without the category breakdown

Weak: Chart entry: "FLACC 5. Tylenol given."
Strong: Chart entry: "FLACC 5 (Face 1, Legs 1, Activity 1, Cry 1, Consolability 1) at 1430. Acetaminophen 10 mg/kg PO given at 1435. Reassess at 1515."

A total of 5 does not tell the next nurse whether the pain presents as global unease (each category at 1) or as two categories at 2 plus a comfortable third. Documenting category scores preserves the clinical picture for reassessment.

Not attempting to console before scoring Consolability

Weak: The nurse walks into the room, watches for 15 seconds, documents Consolability = 2, and leaves.
Strong: The nurse attempts comfort measures (positioning, caregiver presence, talking to the patient) for at least 30 seconds, observes the response, and then documents Consolability based on whether the patient calmed, was distractible, or remained distressed.

Consolability is the only category that requires an action from the nurse before scoring. Without attempting comfort, the Consolability score is a guess rather than an observation.

Skipping reassessment after the PRN analgesic

Weak: FLACC 7 at 1400 with morphine 0.1 mg/kg IV given. No reassessment documented until the 1700 routine check.
Strong: FLACC 7 at 1400, morphine 0.1 mg/kg IV given at 1405, FLACC 2 reassessed at 1425, continued monitoring per unit policy.

Opioid reassessment is both a clinical and a legal requirement. A PRN given without a documented reassessment score is an incomplete pain management record and a common survey finding.

Mixing FLACC with the 0-10 numeric scale in the same entry

Weak: Chart entry: "Pain 7/10 (FLACC)."
Strong: Chart entry: "FLACC 7" or "Pain 7/10 self-report." Pick the tool that fits the patient and document it by name.

FLACC and the 0-10 numeric scale are different instruments with different validation populations. Writing "7/10 (FLACC)" conflates them and makes chart audit and trend tracking harder. The total is on a 0-10 range, but the scale is FLACC, not numeric.

Case Example

JordanAge 4 — Postoperative day 0 after laparoscopic appendectomy
fictional patient

Scenario

You are the evening shift nurse. Jordan came out of the PACU at 1600 after a laparoscopic appendectomy. At 1830 you enter the room to do a scheduled pain assessment. Jordan is lying on his right side with knees drawn up. His face is frowning and he whimpers when you pull back the blanket to check the dressing. His mother is at the bedside holding his hand. When you say "hi Jordan, can you tell me how you feel," he turns his face to the wall and does not answer. His IV hydromorphone PCA basal is running; last demand dose was at 1700.

Chart Entry

Pain assessment 1830:

FLACC total: 6
- Face: 2 - frequent frown, jaw clenched when dressing touched
- Legs: 2 - knees drawn up toward abdomen, guarding posture
- Activity: 1 - squirming when repositioned, tense
- Cry: 1 - whimpers with dressing contact, no steady crying
- Consolability: 0 - calmed when mother held hand and I stopped dressing check; responds to maternal presence

Clinical context: nonverbal (turned away when asked); PCA basal running; last bolus 1700.

Intervention: PCA bolus delivered 1832; position changed to right side with knees supported on pillow; mother coached on PCA button technique.

Reassessment at 1900: FLACC 2 (Face 1 - slightly withdrawn but no frown, Legs 0 - extended and relaxed, Activity 1 - shifting position occasionally, not guarding, Cry 0, Consolability 0). Continue scheduled assessment q2h and PRN.

Key points from above chart entry

Category breakdown documented:
All five scores listed individually so the next nurse sees the pain presents as Face and Legs, not crying.
Consolability scored based on actual attempt:
Mother was already present; the nurse observed the calming response before scoring 0, rather than assuming.
Intervention + reassessment within 30 minutes:
PCA bolus at 1832, reassess at 1900 - within the standard 30-minute post-PRN window.
No numeric self-report attempted:
Jordan turned away when asked, which is an appropriate trigger to switch from self-report to FLACC. The chart notes the trigger so the tool choice is defensible.

Pro Tips

  • Always try self-report first, document why you switched: If a child is old enough to point at Wong-Baker faces or speak a number, try that before FLACC. When you switch to FLACC, write one line in the chart about why (nonverbal, emergence delirium, sedated, cognitively impaired). This protects the score from an audit question about tool choice.
  • Observe for the full rated period: The original FLACC protocol specifies a 1 to 5 minute observation window. A 10-second glance at a sleeping child is not a FLACC. Build the observation into the standard pain assessment rather than trying to score on the fly.
  • Compare Face to a baseline photo or parent description: A furrowed brow can be pain or can be the child's resting face. If there is a baseline admission photo, check it. If there is not, ask the parent "does he always look like that when he is comfortable." A two-sentence parent quote in the chart strengthens the score.
  • Score Consolability after, not before, a comfort attempt: Walking in, watching for 15 seconds, and scoring 0 on Consolability is a guess. Try positioning, caregiver presence, or talking to the patient, then score based on the response. This single habit changes FLACC accuracy more than any other.
  • Pair every opioid FLACC with a reassessment within 30 minutes: The reassessment score is what closes the clinical and legal loop. Document the intervention time, the reassessment time, and the new FLACC. A PRN opioid without a documented reassessment score is a survey finding waiting to happen.

Step by Step

  1. Confirm FLACC is the right tool for this patient: If the patient can self-report pain reliably via the numeric scale or Wong-Baker faces, use that instead. If the patient is nonverbal, sedated, or cognitively impaired, FLACC is appropriate.
  2. Observe the patient for 1 to 5 minutes: Watch the patient without intervening. Note facial expression, leg position, body activity, and whether the patient is crying or vocalizing.
  3. Score each of the five categories 0 to 2: Face, Legs, Activity, Cry, and Consolability each get a 0, 1, or 2 based on the published rubric. Consolability requires a comfort attempt before scoring.
  4. Sum the categories for a total of 0 to 10: Total 0 = relaxed, 1-3 = mild discomfort, 4-6 = moderate pain, 7-10 = severe pain.
  5. Intervene and reassess: For scores 4 and above, apply a pain intervention, such as an as-needed (PRN) analgesic, a nonpharmacologic measure, or provider notification. Reassess the FLACC within the window appropriate to the intervention and document the new score.

Frequently Asked Questions

What does a FLACC score of 4 mean?
A FLACC score of 4 falls in the moderate pain range (4-6). It means the patient is showing behavioral signs of pain across multiple categories and should prompt a review of scheduled and as-needed (PRN) pain orders, an intervention if clinically appropriate, and a reassessment within the window your facility sets. A 4 is not a "wait and see" score; it is a score that should drive a decision.
Is FLACC only for pediatric patients?
No, FLACC is not only for pediatric patients. It was validated for children ages 2 months to 7 years; the revised FLACC (r-FLACC) was validated for children with cognitive impairment and is widely applied to cognitively impaired adults and other nonverbal adults, such as those with advanced dementia or emerging from anesthesia. For adult intensive care unit (ICU) patients, the Critical-Care Pain Observation Tool (CPOT) and the Behavioral Pain Scale (BPS) are the usual choices, not FLACC; check your facility policy for which behavioral scale it prefers.
How is FLACC different from the numeric 0-10 pain scale?
FLACC is an observational tool, while the numeric 0-10 pain scale is a self-report tool. With the numeric scale, the patient states their pain intensity; with FLACC, the nurse rates five behavioral categories the patient displays. Both produce a score on a 0-10 range, but they are measuring different things. Self-report is preferred when the patient can reliably speak or point; FLACC is a fallback for patients who cannot self-report. You should not use both tools on the same patient at the same time or mix their scores in a single chart entry.
Do I need to document all five FLACC category scores, or only the total?
Best practice is to document all five category scores plus the total. A total of 5 with one category at 2 looks very different clinically from a total of 5 with five categories at 1 each, and the next nurse needs the breakdown to know what to watch for. Many facilities require the category-level documentation; check your charting policy. In NurseChartingPro, the total enters the structured field and the category-level detail can be added in the notes section of the pain assessment.
How often should I reassess with FLACC after giving a pain medication?
Reassessment timing follows the medication and your facility policy, not the FLACC tool itself. After an IV opioid, reassess within 15 to 30 minutes. After an oral analgesic, reassess within 45 to 60 minutes. After a scheduled non-opioid like acetaminophen, reassess at the next standard interval. Document the reassessment FLACC with the time; an intervention without a reassessment score is an incomplete pain management record.
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