There are various ways pain can be measured by hospital staff members, depending on the organization.
At Altru Health System (AHS) in Grand Forks, ND, the patient receives a comprehensive initial pain assessment upon admission. Then every shift thereafter, an ongoing pain assessment is completed.
To ensure that pain assessment and reassessment were happening in patient documents, AHS conducted monthly chart audits.
The data—collected from these monthly chart audits for the Joint Commission Provision of Care standards—revealed low compliance with the need for timely documentation of pain reassessment.
The Pain Management Committee at AHS began revisions of the pain assessment policy after recommendations for policy revisions from Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, senior consultant with The Greeley Company, a division of HCPro Inc., in Marblehead, MA, and Janelle Holth, RN BSN, AHS' regulatory compliance coordinator.
Reassessment for time and policy
Chart audit data indicated that the reassessment for inpatients was occurring, but not documented within the timelines written in the pain assessment policy.
"For example, if a nurse gave a patient medication through an IV, which is supposed to be reassessed within a half hour, it was not happening within that timeframe," says Holth.
AHS has electronic medical records, so even though the nurse was able to reassess the pain timely and document before the end of their shift, the reassessments were not making it back into the records within the required time.
The location of the computers was another complication added to the documentation of pain reassessment within the timelines.
The computers are located in the hallways and not at the bedside, which adds steps to the flow of work processes.
With discussion and clarification of the requirements, the timeliness for reassessment was removed from the policy. This allowed the nursing staff to focus on pain management for the patient, without interrupting the care for the patient.
The nursing staff was also able to reference the time pain was reassessed within their documentation before the end of their shift.