I've been asked to help ensure that my facility meets JCAHO pain standards. Our
policy needs updating, and if anyone cares to share a policy, that would be
great, but that's not why I'm contacting the L.
Presently, we ask the exact same questions (use the same CDS) for pain on
admission, as part of the shift assessment 2-3 times every 24 hours, and then
again each time the patient is medicated. This is not working for us. The
nurses see the same thing over and over and say "I already charted that once."
Or they find another screen that has a lot of free text queries to enter a
narrative account, because they don't like this particular screen, and of
course, their narrative doesn't capture the data we want and can't be
aggregated.
We're talking about creating 3 different groups of queries (representing the 3
different phases of assessment described), which might overlap to some extent.
In general, we see that the pain intervention screen that is filled out at the
time the patient needs a pain med would be focused on this specific pain event.
We think the shift assessment would take a step back, perhaps with questions
such as "have you had any pain in the last 24 hours", "is the pain management
you're receiving working", "is the pain changing in intensity or frequency",
"is there anything else we could do" etc. The admission assessment would get
even more global, and in addition to defining something of the patient's
experiences with pain and pain meds, and identifying current pain, might be a
place to document a few patient education-related queries.
I would love to see/know how you have differentiated between the questions
asked at the time the patient enters your system, those asked as part of the
routine shift assessment, and those that comprise the assessment/reassessment
at the time the nurse is intervening for pain. I've spent hours searching the
net without finding anything that makes me say "Eureka!"
Screen shots are always great, but even a description of how you approached the
design of the queries used for these 3 different scenarios (admission, shift
assessment, intervention); questions that have worked well for you; holes that
you have found in your documentation; general comments, etc. would be of value.
Thanks, Sharon
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