documentation & pain

Was there a way to validate that the pain medication was given? Who ultimately was responsible for this patient?

I'd chart it as you did with just sticking to the facts and not adding anything additional to the info. For example I wouldn't put "screamed in pain like I've never heard before." I'd put it as "patient expressed pain" and then put anything they may have said verbally if it is pertinent. I'd have asked the patient to rate the pain and inquire if there was pain AFTER that needed to be addressed still.

But yeah basically how it happened short and sweet. Name the nurse that removed it since it wasn't you like such - I cut suture. Janice RN removed drain.

The only hangup I really see is that the other staff verbalized that pain medication was given. I wouldn't put that they merely stated it, I would make sure it was actually done before charting as such.

But I'm new, and look forward to the input of those more experienced.

Your obligation is to chart the facts of what happened as factually as possible. Remember that the documentation is simply a record (legal) of what was done to and for a patient. It is the best protection you will have if you are ever deposed in a legal matter regarding a patient you cared for. You may certainly chart that another nurse reported something to you being careful not to play "he said/she said games". You charting should reflect how the patient was doing after the procedure and the pain.

Unfortunately, drains are painful oft times when they are removed. Hence the premedication. Unfortunately, whatever was ordered was obviously not adequate. Sounds like you are perhaps a newer nurse and this was why another nurse assisted you? Good luck!