Documenting pain and pain medications

  1. 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
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    About fetch33

    Joined: Jul '06; Posts: 77; Likes: 25
    Orthopedic RN; from US
    Specialty: 30 year(s) of experience

    18 Comments

  3. by   dunkinut
    This is what is wrong in nursing today! Its not about the documentation, its about the best care of your patient, and if it takes more time to check these important assessments, then it takes more time; Period!

    I dont know about your institution and what you are allowed to delegate, but wouldn't it be easy and effective to utilize your nurse extenders and CNA's to get your assessments done and proceed from there? These important assessment parameters should not be looked upon as a hassle, they should be utilized to the best degree for the best care of your patient! If its a matter of no time for the assessments, then its time to take the issue to those in charge, not take it out on the patient and give them less than top notch care!
  4. by   fetch33
    Quote from dunkinut
    This is what is wrong in nursing today! Its not about the documentation, its about the best care of your patient, and if it takes more time to check these important assessments, then it takes more time; Period!

    I dont know about your institution and what you are allowed to delegate, but wouldn't it be easy and effective to utilize your nurse extenders and CNA's to get your assessments done and proceed from there? These important assessment parameters should not be looked upon as a hassle, they should be utilized to the best degree for the best care of your patient! If its a matter of no time for the assessments, then its time to take the issue to those in charge, not take it out on the patient and give them less than top notch care!
    You know, I have been a nurse for over 20 years. I rely a lot on my physical assessments and experience for my patient care. To be told I have to count respiratory rate and get and oximeter reading on a healthy, few day post-op patient at 1 am is rediculous. It takes up time that doesn't need to be taken up. And no, we don't have CNA's or techs on the night shift where I work. It is all primary care. Do you count respirations and do an O2 sat check when you give a pain pill? Do you do it when you reassess pain in 1 hr? That is what is being asked.
  5. by   morte
    fetch, i havent run across this yet......i would ask your NM for the "notification/announcement" from JACHO....i would be interested my self
    getting resp rate is not so much an issue.....but the POx thing is silly unless the original was off
  6. by   ginger58
    My NM wrote our pain flow sheet. Each 8 hour shift has to chart something on the sheet, even if it's "Denies pain". If that's the case that's all we chart plus date and time and sedation level. On the same line is pain reassessment. If this isn't a respiratory problem we don't chart RR, sat. We make a comment about if it did or didn't help and the pain score. Any routine or prn pain meds get documented on the sheet, but not on the MAR.
    At first it was hard getting used to not seeing the time given on the MAR but now I find the flow sheet most useful.
    Fetch33, I think someone at your facility is on overdrive!
  7. by   burn out
    Our new policy is to chart pain assessments q4h on everyone whether they are having pain or not. In between the four hours if you give them pain meds you have to go back to the pain assessment graph and chart the rating 0-10, where at , level of consciousness, and what you did (to include pain med but turn repostion, ice or heat pack) then go back in 30 min to reevaluate and chart the response. This is pain when you have completed all that for every person you give pain med to.
  8. by   withasmilelpn
    Quote from dunkinut
    This is what is wrong in nursing today! Its not about the documentation, its about the best care of your patient, and if it takes more time to check these important assessments, then it takes more time; Period!

    I dont know about your institution and what you are allowed to delegate, but wouldn't it be easy and effective to utilize your nurse extenders and CNA's to get your assessments done and proceed from there? These important assessment parameters should not be looked upon as a hassle, they should be utilized to the best degree for the best care of your patient! If its a matter of no time for the assessments, then its time to take the issue to those in charge, not take it out on the patient and give them less than top notch care!
    What is wrong is we don't have time to do all the documentation and take care of our patients. We have too many patients to get overly involved in charting what we do or don't do. I always make sure there are no signs of resp depression. I remember when we didn't have pulse ox machines readily available and I could still acurrately tell when I needed to intervene my patients behalf. The insurance companies are the ones that started dictating when they would pay for the use of o2 in facilities like LTC and Home care based on sats. Thus requiring the use of pulse ox readings and documentation q shift. I also always tell my patients to let me know as well if their pain med is not working. Trying to get people to tell me what their pain is on a number schedule is a really abstract idea for some people and takes a long time to explain. I'm just curious and mean no disrespect, dunkinut are you in a position that involves bedside care or management? I do believe that perhaps inservices to be held on what constitutes good care in pain management and the rationale behind but documenting on the minutia sp involved is unneccessary (and annoying!)
  9. by   ginger58
    [QUOTE=withasmilelpn;2109386]What is wrong is we don't have time to do all the documentation and take care of our patients. We have too many patients to get overly involved in charting what we do or don't do. I always make sure there are no signs of resp depression. I remember when we didn't have pulse ox machines readily available and I could still acurrately tell when I needed to intervene my patients behalf...Trying to get people to tell me what their pain is on a number schedule is a really abstract idea for some people and takes a long time to explain."

    I have to absolutely agree. I have enough clinical judgement and experience not need a sat reading in a lot of cases. I also find the Q4h pain rating a pain as in some cases people haven't had any pain in days. They're not in for pain.

    Getting a pain rating isn't always an easy thing. It's a simple concept to us but to some people it's an abstract idea. No matter how I explain the scale they aren't committed to stating a number or they're impaired and can't.
  10. by   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
  11. by   jill48
    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
    What is "negotiated pain level"?
  12. by   RNsRWe
    Ridiculous. I'd be happy if I had enough time in my shift to give the pain meds and chart, let alone add new stuff to assess! I do ask, when I give pain meds, where the pt is on a scale of 1-10, but mostly because our care plans have a page for marking down times the pt expresses pain (or "denies"). I don't have any set times, but it is expected to be addressed at least once per shift. Sometimes I've written down three pain scale episodes per pt, sometimes one "denies". But in no case am I going to look at the clock and spend time doing resps and pulse ox on as many as nine patients just for the sake of MORE charting!

    I'd want to see the JCAHO "requirement" in writing first before I did that.
  13. by   fetch33
    Quote from jill48
    What is "negotiated pain level"?

    This is something we already have to do. It is the level of pain that the patient states is tolerable to them.
  14. by   RNsRWe
    Quote from fetch33
    This is something we already have to do. It is the level of pain that the patient states is tolerable to them.
    Ah, what we refer to as the "comfort level goal". Which is decided during the admission/assessment process, which is in itself absurd. "I know you've been writhing in pain in the ED for the last five hours and now are half snowed on pain meds, but what number on the scale can we mutually agree is an acceptable, comfortable level of pain for you to have, and for us to work toward?"

    ROFL....if it was ME, I'd say "get my butt OUT of pain, NO pain is the goal, isn't it?!?"

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