Improving Patients\u27 Pain Management Through Proper Documentation

The aim of this project was to improve pain documentation on the Surgical Unit as a means to enhance caregiver communication on finding the best methods to manage patients’ pain. Effectively managing patients’ pain leads to better patient outcomes, increased patient and nurse satisfaction, and decreased length of hospitalization. The setting is a not-for-profit hospital in Southern California. The microsystem selected is the 32-bed capacity Surgical Unit that mainly admits pre- and post-surgical patients, but also accommodates non-surgical, telemetry, and trauma cases. To improve pain assessment documentation, collaboration was sought with the multidisciplinary team (IT department, clinical nurse specialists, and a nursing task force), to create an easier way for nurses to document a pain assessment with each administration of a pain medication. Initiating changes to the eMAR began late February 2016 and presented to the Surgical Unit staff during the first week of March 2016. Prior to implementation, chart audits were performed between January to February 2016 and found that assessments were only being performed 80% of the time. Changes to the methods of documentation in the eMAR, staff in-services, and the distribution of educational materials has raised compliance to 87%. Sustainability is expected to prevail as the intervention has stakeholder support, is in line with the institution’s procedures, and has perceived benefits from staff members