Wong-Baker FACES Pain Rating Scale

What the Wong-Baker FACES scale is

Donna Wong, a pediatric nurse, and Connie Baker, a child life specialist, developed the scale in the early 1980s to help young children tell adults how much they hurt. The Wong-Baker FACES Foundation holds the copyright (1983) and controls how the scale is copied and used.

The patient looks at a row of six cartoon faces. The first face is happy and shows no hurt. Each face after it shows more hurt, and the last one shows the worst hurt the patient can imagine and is drawn with tears. The patient picks one face, and you record the number under it.

It is a self-assessment tool. The foundation states that it measures pain only, not mood or emotion, and that it should not be used for unresponsive patients or by a third party to rate someone else's pain.

The wording above is our paraphrase, not the official face captions. Only even numbers are possible: a patient cannot choose 3 or 7 on this scale.

Who the scale is for

The foundation describes the scale for people ages 3 and older. Nursing texts recommend it for children and for anyone who cannot rate pain with numbers, such as adults with limited literacy, a language barrier or mild cognitive impairment who can still understand and point to a picture.

• Preschool and school-age children who can point to a face but do not yet use numbers reliably
• Older children and adults who prefer pictures to numbers
• Patients who speak another language, since the faces need little translation
• Adults with mild cognitive impairment who can still self-report

Do not use FACES for infants, unresponsive or sedated patients, or anyone who cannot choose a face. Switch to a behavioral tool such as FLACC.

How to use the Wong-Baker FACES scale correctly

Use the official scale sheet from the foundation, and follow its instructions. The steps below summarize good practice in our own words.

• Check that the patient is awake, can see the faces and can point or name a choice.
• Point to each face and explain that the faces show how much something hurts, from no hurt on one end to the worst hurt on the other.
• Make clear that the faces describe hurt, not happiness or sadness, and that crying is not required to pick the last face.
• Ask the patient to choose the face that shows how much they hurt right now.
• Record the number that goes with the chosen face, plus the location of the pain.
• Reassess with the same scale after an intervention, within the time your pain policy sets, so scores can be compared.

Common mistakes with the FACES scale

Most errors come from turning a self-report tool into an observation tool, or from mixing up pain and emotion.

• Matching the face to how the patient looks instead of asking which face shows how they feel. A calm child can still hurt a lot.
• Choosing the face for the patient, or letting a parent choose it. The foundation says the scale is not for third-party ratings.
• Using it to rate fear, anxiety or sadness. The happy first face and the tearful last face can pull scared or upset children toward the extremes.
• Recording odd numbers or halfway points. Each face has one fixed score.
• Switching between FACES and the numeric scale for the same patient, which makes the trend hard to read.
• Using a copied, redrawn or modified version of the faces. The foundation does not allow changes without permission.

FACES vs the 0-10 numeric scale and FLACC

All three tools give a 0-10 score, but they collect it in different ways. Pick the one that fits what the patient can do, and use self-report whenever the patient can give it reliably.

A 2010 systematic review in Pediatrics found that children often prefer the Wong-Baker faces, but its smiling and crying anchor faces can confound pain with emotion. The authors saw no strong reason to change the scale a unit already uses in clinical practice.

How to document a Wong-Baker FACES score

Write the score with the scale name so readers know it came from a faces tool, not a numeric rating. Add the context and what you did about it.

Example: "Pain 6/10 on Wong-Baker FACES, right forearm, at rest. Patient chose the face himself. Comfort measures and ordered analgesic given. Reassessed at 60 min: 2/10 on FACES."

• Scale name and score out of 10
• Pain location and whether at rest or with movement
• Who chose the face (the patient)
• Intervention given
• Reassessment score with the same scale and the time

Getting the official scale and permission to use it

The faces, their captions and the instructions are copyrighted by the Wong-Baker FACES Foundation. This page describes the scale in our own words and does not reproduce it. Get the official version directly from wongbakerfaces.org.

The foundation offers the scale to individual clinicians and has separate access paths for personal, healthcare, research, commercial and publishing use. Its terms state that use in facilities, electronic health records, apps, commercial products or publications will likely need a licensing agreement and a fee, and that no modified version may be used without permission. Check the current terms, or ask your facility, before printing or building it into a system.

The scale supports, never replaces, your clinical judgment and your facility's pain policy.