(I posted this originally on the Pain Management Forum but it didn't seem to be getting a lot of looks and thought I'd try cross-posting here - Thanks!)
I'm a clinical manager at my hospital attempting to revises the way we assess pain and pain control. Although I know mostly what I would like to see I'm also cognizant of the workload most of the staff have (anywhere from 6-9 pts each) and am trying to develop something that does not dramatically increase the workload (I find that the more you try to add on the less reliable the added work is).
So, to that end - this is currently how we assess pain:
Pain - present or absent
6 pain sections (only chart on the number of places pt has pain - ex if pain present in abd and legs you would chart on pain#1 and pain #2)
Reassess pain intensity
Motor Block for epidurals
Number of doses given
Number of bolus
Total given ml
Total drug given (mg or mcg)
New syring hung
All of this charting exists under our assessment portion (computer charting) as is usually charted on 1 time per shift. The medications (other than pca/epidural) are charted on another screen and do not flow across. So, for example if dilaudid is given it is charted on the electronic MAR and thenyou have to click on another screen to see what the pain score is and whether or not relief was achieved (often times not charted on or somehow charted at the same time as the original pain score was charted). This leads to a very fragmented system of pain assessment and I believe leads to inneffectual pain relief.
So to make a long story short (too late) this is what I would like to change. I like a lot of what the assessment asks for but I think realistically it is too much for the floor staff to do each time they give a pain med. What I would like to do is develop a new screen that could be charted on when a pain med is given - something relatively simple that pain relief can easily be gauged from. The assessment above can not even be viewed on the same screen at one time, you have to keep scrolling down.
So finally my question, what are the essential questions that need to be asked when documenting a pain med? These are my thoughts already:
Pain med given / dose
Alternative Intervention tried
Did you receive adequate pain relief last time from this treatment?
Acute pain or Chronic pain
and if on a PCA at least every 2 hrs for 1st 24 or longer if pain not relieved
Actual dose received
Any other ideas or suggestions - please remember I want to simultaneously achieve good pain relief and not overburden the floor staff with documentation. Also I would have them chart on the assessment located at the top q 4hrs until pain relief achieved and the q 8 hrs.
Thanks in advance
Quote from GardenDove
(I don't totally 'make up' a number, but I guessimate, based on what the pt says. Why hassle someone for a G-D**m number when they're hurting?)
I usually just quote what they say in quotes.(lol I guess that is the only way to quote something) Usually if they give me that blank stare after I explain the pain scale I know the number really will mean nothing. I think it is crazy to expect the patient to figure out the pain scale if they state they are in pain. But then again I am not really in charge of running the show.
Last edit by maryloufu on Dec 9, '06
: Reason: My crazy first sentence