Documenting pain and pain medications - page 2

We just got a new pain documentaion protocol. Supposedly, it is required by JCAHO for our total joint patients, therefore, it is going to be used on all of our patients on ortho. You have to document... Read More

  1. by   janetjanetbobanet
    Quote from morte
    hmmmm i work the noc shift (usually) so, i am going to medicate someone for "pain" (probably insomnia) at 2400, go back at 0100 and wake up a resting peacefully-rr=14 patient to get a pulse and pox?...i think not
    Me neither. The system forces you to guess.
  2. by   NRSKarenRN
  3. by   Bluehair
    I guess it depends on the parameters at your facility on what they want you to chart for pain management. We have 2 different ways to measure pain - verbal scale (0 - 10) and non-verbal, where you document things like facial grimacing, etc. It helps determine apparent level of pain if they are having difficulty communicating (i.e. peds, aphasia, etc.) I take their vital signs/p ox about 15 minutes after med is given to show they had no initial adverse respiratory affects from the med. We are supposed to reassess their pain 30 - 45 min later. If they are sleeping I use the non-verbal scale to document evidence of pain relief.
    I agree with the OP - isn't making sure they didn't have an adverse reaction to their pain med the best care? I have seen patients (as in more than one) suddenly not be able to handle morphine and have a respiratory arrest as a result. One monute they were up in the chair, walking at the bedside, got back to bed, sat's 97% - got their IV pain med and BAM, turning purple and not breathing 5 minutes later. Yeah it's a pain but it's still the best thing to do. Would hate to think how I would have felt if that guy had died because we hadn't checked on him.....
  4. by   withasmilelpn
    Always check on your patient, just don't document on them unless they have no relief or an adverse reaction, how about that approach? I just want to give my patients the best, most efficient care possible without writing and writing and writing and writing. My notes get this almost cookie cutter approach now and almost in no way reflect the sheer amount of time I spend or what I actually do for my patient. My facility now wants us to do lung assessments each time I give a breathing treatment, even routine inhalers,and ones that are long term CoPDer getting Duonebs q 6 for years. The lung sounds are involved are to be done before and after and we are to document the minutes we assess them and the minutes we give them as well?! Does anyone else think that they are going to start billing for our time or am I paranoid? Why does it need to be documented that way? I have no problem assessing people who clearly need it, but I have too many patients in LTC to get this focused. It is a challange just getting meds and treatments done. Paperwork needs to be cut, not added to!
  5. by   morte
    Quote from withasmilelpn
    The lung sounds are involved are to be done before and after and we are to document the minutes we assess them and the minutes we give them as well?! Does anyone else think that they are going to start billing for our time or am I paranoid? Why does it need to be documented that way? I have no problem assessing people who clearly need it, but I have too many patients in LTC to get this focused. It is a challange just getting meds and treatments done. Paperwork needs to be cut, not added to!
    this is speculation on my part....but i think it probably is a case of not being able to bill for the rx if it isnt doc to have taken a certain amount of tme...which is longer then we know it would take.and if you have say twenty of them in an eight hour shift....10-15 minuter apiece....when are you going to do anything else...and if you are doc that it took that long and you are not taking that long...well we know what that is......good luck
  6. by   Nemhain
    Quote from fetch33
    We just got a new pain documentaion protocol. Supposedly, it is required by JCAHO for our total joint patients, therefore, it is going to be used on all of our patients on ortho. You have to document resp, O2 saturation, any O2 the patient is on, current pain level, negotiated pain level, location, description of pain, LOC, and behavior every time pain is addressed. So I am assuming that just running in and handing pain pills to a patient, on whose pain you have assessed is a thing of the past. Now we have to stop and document O2 saturation and resp rate amongst other things. Oh, and even if the patient states their pain is a 0 out of 10, we still have to address each of these things. Isn't this overkill? There are some patients whom I give pain meds to up to 8 or more times a shift....... when I am going to find the time? Perhaps we can just surgically implant an O2 sat monitor on admission
    I'm on a regular med/surg floor and we have to do that except for the O2 for pain. You should see our charting; you'd fall over and die. I haven't been on my unit for very long, but one of the nurses I work with has been there 10+ years and says that having 6 patients on day shift 5 years ago was so much easier than 4 patients on night shift now because of all of the damn charting.

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