Pain Assessment/Reassessment

Specialties Pain

Published

Can anyone share with me their forms or documentation of pain assessment.......most importantly how you document your reassessement?

Thanks

Bobby

My experience with JCAHO is reassessment of pain levels and effectiveness of medications is always their big issue.

That's one thing I have never understood anout JCAHO terminology--what, exactly, is the difference between "assessment" and "reassessment?" Why not just refer to eah assessment you do--for pain or anything else that would require documentation and possibly an intervention (such as medication or some other tretment) as an ASSESSMENT?

This really bothered me when I was doing chart audits at this little desert hospital in CA. In CA, LVNs are not allowed to assess patients. Yet, I was told by their nurse CEO (a traveler from another state) that they are allowed to REASSESS patients. I think she did not know what the heck she was talking about (well, that was just one of many things she was clueless about.)

How in the heck can you REASSESS a patient if you are not allowed to ASSESS him in the FIRST place? Was she saying that the LVNs are simply using the RN's original assessment as if it was their own assessment, and building a new assessment--or, excuse me, REASSESSMENT--off that? That is, using that as their baseline?

Or is she saying that, even though they cannot do an independent assessment, they can look at the RN's previous assesment, and report to her if things have changed from that, and require intervention? However, again, if they can't assess, then how can they determine if an intervention is required----other than simply reporting what the patient says, or phsyiscal clues (grimacing, moaning, etc.) to the RN? Clue me in, please, someone. I just don't understand the need for the distinction. To me, an assessment is an assessment, and you do continuous assessment (and intervention) as part of the nursing process.

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That's one thing I have never understood anout JCAHO terminology--what, exactly, is the difference between "assessment" and "reassessment?" Why not just refer to eah assessment you do--for pain or anything else that would require documentation and possibly an intervention (such as medication or some other tretment) as an ASSESSMENT?

This really bothered me when I was doing chart audits at this little desert hospital in CA. In CA, LVNs are not allowed to assess patients. Yet, I was told by their nurse CEO (a traveler from another state) that they are allowed to REASSESS patients. I think she did not know what the heck she was talking about (well, that was just one of many things she was clueless about.)

How in the heck can you REASSESS a patient if you are not allowed to ASSESS him in the FIRST place? Was she saying that the LVNs are simply using the RN's original assessment as if it was their own assessment, and building a new assessment--or, excuse me, REASSESSMENT--off that? That is, using that as their baseline?

Or is she saying that, even though they cannot do an independent assessment, they can look at the RN's previous assesment, and report to her if things have changed from that, and require intervention? However, again, if they can't assess, then how can they determine if an intervention is required----other than simply reporting what the patient says, or phsyiscal clues (grimacing, moaning, etc.) to the RN? Clue me in, please, someone. I just don't understand the need for the distinction. To me, an assessment is an assessment, and you do continuous assessment (and intervention) as part of the nursing process.

All that assessing and reassessing could surely get confusing i am currently researching the availability of a distress assessment tool for people who experience difficulty with communication, we are hoping to include such a tool in an integrated care pathway for the terminal phase but are having difficulty finding one with evidence to back it up could you help

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assessment would be evaluating your pt's need for analgesics r/t pain.

i would think reassessment would be the results of the pain med given.

leslie

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assessment would be evaluating your pt's need for analgesics r/t pain.

i would think reassessment would be the results of the pain med given.

leslie

Thanks, Leslie. :)

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