Improving Pain Assessment Documentation In Leukemia Center

In 2022, the Leukemia Center was non-compliant with organizational pain assessment (PA) documentation requirements (goal 95%) with documentation rate of 69%. Nurses, who primarily complete PAs, may encounter multiple barriers including unclear organizational policies, changing documentation requirements, and inefficient documentation practices. Educational materials were developed to inform all staff on institutional policies, current PA documentation rates, step-by-step instructions, and utilization of the Nursing Checklist tool as a visual reminder to double check completion of documentation. Six months post-implementation, the average rate of PA documentation compliance increased to 87%. To achieve substantial change in nursing PA documentation compliance, the following were necessary: guidance on the policy and specific documentation criteria, staff coaching and educational efforts, direct leadership involvement, audit, feedback, clear accountability, and alignment with performance goals.https://openworks.mdanderson.org/acif24/1008/thumbnail.jp