Re: [MEDITECH-L] Pain assessment and reassessment documentation

[Brenda Wiley]

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Hi Lorraine,

 

RE:  pain assessment and reassessment, after going thru various types of notes, interventions, etc, that weren't consistently used, we now use a GET-KEY canned text in the patient notes (see below).  This is entered AFTER evaluation of the pain med's effectiveness, so if morphine is given at 11am and its effectiveness evaluated at 11:30, this note is entered at 11:30.

 

The nurses like that they have to enter only ONE note, and with the canned text, the data entry is actually very quick and the one note charting pain, what was done, what was given, when, and how well it worked can all be done in less than 30 seconds.  JCAHO, in their last visit, said they really like this.

 

Complaint, Location of pain: []
Intensity (0-10 pain scale):  []
Character of pain: [g NURTCUPC]
Duration: []
Acknowledges understanding of Pain Management options: []
Comfort measures used: []
Medication, route, dose: []
Time of medication administration: []

Patient response (pain scale 0-10): []
Time of response: []

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RE:  medication teaching: 

 

We utilize a subscription service (Krames) which is an online source that will print patient education sheets on a wide variety of drugs.  Additionally, we have a policy written that includes the following language:

 

 Medication teaching will be documented in Meditech on the Teaching
 Record.  The goal of medication teaching is to allow safe and effective use of medications.  Content should include as appropriate:

a) indication
b) dose
c) frequency
d) route
e) major side effects
f) precautions

 

On our Teaching Record (which is a form used by all disciplines for all types of teaching) we have the following queries:

 

Medication Teaching Done? Y/N

Meds for which teaching was provided:

         (this query is skipped automatically if the former query is answered with a 'N')

Teaching done per P&P? Y/N

 

We have taught our nurses to, in addition to answering Y to the two Y/N questions, enter "Krames sheet given and reviewed with patient" in the portion of the CDS set up for what was taught.

 

Hope this helps.

 

Brenda Wiley, RN

Transylvania Community Hospital, Inc.

 

Lorraine Greene <[EMAIL PROTECTED]> wrote:

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Our facility is in the process of trying to get increased compliance with pain assessment and reassessment documentation. We also are falling out on the documentation of alternative measures and patient/family education about the pain medication given. Is there anyone out there that is willing to share screen shots of their documentation?  Thanks !

 

Lorraine Greene RN

Clinical Informations Systems Coordinator

Houston Healthcare

478-322-5149

[EMAIL PROTECTED]

 

 

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