Documentation of Pain Reassessment

[LindaCordero]

Hello all!

I am looking for some assistance with increasing our documentation of pain reassessment. One of our performance improvement measures for the joint replacement disease specific certification from the joint commission, is documentation of pain reassessment within one hour. While I am certain my nurses are completing the reassessments (our patient satisfaction numbers for controlling pain are excellent), the documentation is just not happening. I have worked for over a year to increase compliance and we are currently on about 75%. We have done several educational offerings as well as one on one training for those struggling with documentation. We are supposed to be at 90% at least and our recertification is coming up quick and I would like to better these numbers.

Anyone have any ideas?

Thanks so much for your help!

Linda Cordero, RN, BSN, ONC

[tewdles, RN]

Post the numbers with the goals as often as you run them. Engage the staff in understanding that this is a measurement of THEIR professional documentation which is required as part of their practice.

Is there an issue with the form used to document the pain f/u? Does it need to be revised to better reflect the practice? Ask the staff why THEY think the numbers are not reflecting their good practice.

Bottom line, the staff must buy into the expectation and practice requirements if they want to remain a valuable member of the team. Management's job is often to help them with the "buy in".

[Turd Ferguson]

We have a similar problem hospital wide, here is a basic flowsheet of what has transpired.

1. Establish expectations for reassessment of pain (within 30 minutes for IV meds, 1 hour for PO, "timely manner" for other interventions such as hot/cold compress, repositioning, etc...). As you mentioned, pain was being treated but documentation was just not happening.

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2. Hold nurses accountable for documentation, random audit type of scenario. Still not working, documentation of reassessment still low.

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3. Charge nurse audits ALL pain interventions and reassessments for ALL nurses on the floor every 4 hours. This is the most recent policy put into place. It takes massive amounts of time, and sometimes prevents the charge nurse from fulfilling other duties... but it's worked so far. I have mixed feelings.

[Penelope_Pitstop, BSN, RN]

We use electronic medication administration recording software that automatically generates a timed task 30 minutes after IV pain medicine is administered and 1 hour after PO pain medicine is administered. People still complete the tasks late but at least they are completed!