Charting pain assessments

[patwil73]

Hello everyone,

I'm a clinical manager at my hospital attempting to revises the way we assess pain and pain control. Although I know mostly what I would like to see I'm also cognizant of the workload most of the staff have (anywhere from 6-9 pts each) and am trying to develop something that does not dramatically increase the workload (I find that the more you try to add on the less reliable the added work is).

So, to that end - this is currently how we assess pain:

Pain - present or absent

6 pain sections (only chart on the number of places pt has pain - ex if pain present in abd and legs you would chart on pain#1 and pain #2)

Pain Location

Pain intensity

Pain description

Accompanying symptoms

Reassess pain intensity

Consciousness Scale

Respiratory Scale

Motor Block for epidurals

PCA/epidural Med

Concentration

Dose

Lockout

Basal

Bolus

Attempt number

Number of doses given

Number of bolus

Total given ml

Total drug given (mg or mcg)

total remaining

Narcan given?

New syring hung

Tubing change

Intervention

Intervention response

All of this charting exists under our assessment portion (computer charting) as is usually charted on 1 time per shift. The medications (other than pca/epidural) are charted on another screen and do not flow across. So, for example if dilaudid is given it is charted on the electronic MAR and thenyou have to click on another screen to see what the pain score is and whether or not relief was achieved (often times not charted on or somehow charted at the same time as the original pain score was charted). This leads to a very fragmented system of pain assessment and I believe leads to inneffectual pain relief.

So to make a long story short (too late) this is what I would like to change. I like a lot of what the assessment asks for but I think realistically it is too much for the floor staff to do each time they give a pain med. What I would like to do is develop a new screen that could be charted on when a pain med is given - something relatively simple that pain relief can easily be gauged from. The assessment above can not even be viewed on the same screen at one time, you have to keep scrolling down.

So finally my question, what are the essential questions that need to be asked when documenting a pain med? These are my thoughts already:

Pain intensity

Pain med given / dose

or

Alternative Intervention tried

Did you receive adequate pain relief last time from this treatment?

Acute pain or Chronic pain

and if on a PCA at least every 2 hrs for 1st 24 or longer if pain not relieved

#attempts

Actual dose received

Any other ideas or suggestions - please remember I want to simultaneously achieve good pain relief and not overburden the floor staff with documentation. Also I would have them chart on the assessment located at the top q 4hrs until pain relief achieved and the q 8 hrs.

Thanks in advance

Pat

[softstorms]

As the QA on pain in my facility, I also have a problem with recording pain scales and treatment. documentation is always a problem. If you find a resolution to this, please share.

[lezanne]

In outpatient we use the pain scale of 0 to 10 then have another written complete assessment if the patient has pain. The problem I see is that most of the patients having pain rate their pain at 5 or above no matter what medication or treatment they are on.

[sharann, BSN, RN]

Patwil73,

I agree with you that your current pain screen is way overboard for any nurse on any floor in an acute hospital (not a pain nurse but normal staffers with too many patients already). I think that the following should be done with each pain med:

Med given

Pain rating by patient or nurse if pt unable or unwilling

Follow up in 30 min to 1 hour depending on route with #rating.

If on PCA there is a flow sheet usually and this should be updated q shift or with titration changes only.

Sometimes TOO much charting can cause more legal issues later.

I think it is great you are actively thinking of the nurses practical ability to manage this type of overboard charting.