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Advanced Search November 1999 - Volume 29 - Issue 11
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Institutional UsersAccess through Ovid® Not a Subscriber?Buy Subscribe Request Permissions You can read the full text of this article if you: Log In Access through Ovid Charting Tips: PDF Only CHAPMAN, GINA FAGAN RN, MSN Clinical Development Specialist • Warminster Hospital • Warminster, Pa. Nursing:
November 1999 - Volume 29 - Issue 11 - p 25-27 Nursing Quick Links
Related ArticlesPain management is an essential element of patient care, and pain management includes not only the accurate assessment and treatment of pain, but also complete documentation of findings, and that’s what we’ll be talking about today. Almost all hospitals and most physician’s offices have switched from paper health records to electronic health records, and the software may determine how information about pain is actually recorded. For example, some may require only narrative descriptions while others provide checklists of descriptions from which to choose. However, what should be recorded remains constant. Documentation about pain should include:
Facility protocols for pain assessment and documentation may vary but should always be part of the initial head-to-toe physical examination. It’s important not to document pain based solely on diagnosis. Whenever an assessment of pain is carried out, the findings should be documented. Let’s review the necessary elements of documentation one at a time, beginning with the site and description of radiation or referred pain. Try to be as specific as possible, for instance:
When documenting the description and character of the pain, use quotations from the patient if possible, for instance:
Typical pain descriptors include:
For the degree of pain, include the assessment tool utilized, for instance:
Keep in mind that the patient’s self-report of pain is subjective and understanding of the assessment tools may vary. While the 1 to 10 numeric scale is the most commonly used in the United States, people from other cultures, children, and those with confusion or dementia may be unsure about how to respond. Pain is often intermittent, especially chronic pain, so record not only the onset of the current episode of pain but also the onset of this type of pain. For instance:
Next, record the pain frequency. It’s especially important to document any change in pattern.
It’s also important to differentiate among the duration of the current episode of pain, the duration of usual episodes of pain, and the overall duration of this type of pain.
Report any associated observations, both physical and emotional. For example,
If the causative factors are known or suspected, document them with a statement such as, “The patient reports recently drinking beer and eating meals high in purines, including red meat and organ meats.” In addition, document aggravating factors that increase pain, for instance:
If alleviating factors that reduce pain are known, document them because they help to determine an effective strategy to manage pain and assess the patient’s coping skills. For instance, you may document that ice packs, elevation, and pain medication provide some relief. Document any pharmacological and non-pharmacological interventions, including the time, dosage, and route of administration of medications as well as other pain-alleviating interventions. For example: “The right foot was elevated and an ice pack applied to the inflamed area.” Always document the response to interventions. After receiving a parenteral medication, the patient should be assessed after 15 minutes and again at 30 minutes. After receiving an oral medication, which takes effect more slowly, the patient should be reassessed after 30 to 60 minutes. Documentation should be done immediately after the administration of medications to ensure that documentation is not overlooked and that an overdose does not occur because a medication is administered twice. When administering PRN medications, the reason for the administration must always be noted. The patient should be observed carefully for adverse effects, especially with new medications, and the adverse effect documented as well as any steps taken in response to the adverse effect. For instance:
The assessment and documentation of pain should be done on a routine scheduled basis so that pain is not overlooked. However, the frequency may vary according to established protocols and the type of unit and may be adjusted based on the patient’s condition. For example, postoperative pain may be assessed and documented routinely every 15 minutes in recovery and then every hour for 4 hours or until the patient stabilizes and then every 2 to 4 hours. Once the patient’s pain reduces or the patient stabilizes, assessment and documentation may be done every 4 to 8 hours. A patient with chronic pain may be assessed every 4 to 8 hours depending on the type and extent of pain. Documentation of pain for patients utilizing patient controlled analgesia depends on a number of different factors, including the medication, dosage, the lock-out interval, dose limit, the basal dose, the bolus dose, and bolus intervals. A typical schedule is:
Patients’ recovery and functional abilities may depend on the control of pain, and careful documentation about pain can help to guide other healthcare providers and ensure that patients receive optimal care and relief of pain. Thanks for watching and study happy. How do I document a pain assessment for nursing?Nurses can help patients more accurately report their pain by using these very specific PQRST assessment questions:. P = Provocation/Palliation. What were you doing when the pain started? ... . Q = Quality/Quantity. What does it feel like? ... . R = Region/Radiation. ... . S = Severity Scale. ... . T = Timing. ... . Documentation.. Which of the following needs to be included when documenting a pain assessment?Comprehensive pain assessment also includes pain history, pain intensity, quality of pain, and location of pain. For each pain location, the pattern of pain radiation should be assessed (NCI, 2016). A review of the patient's current pain management plan and how he or she has responded to treatment is important.
How do you record pain?Using a pain scale to record the intensity of the pain is useful to describe changes of pain in detail and establish patterns in the pain diary. The intensity is usually recorded on a scale from 0 to 10, with 0 being no pain experienced and 10 being the worst pain imaginable.
How do you write a pain scale?Using the Pain Scale. If you want your pain to be taken seriously, ... . 0 – Pain Free.. 1 – Pain is very mild, barely noticeable. ... . 2 – Minor pain. ... . 3 – Pain is noticeable and distracting, however, you can get used to it and adapt.. 4 – Moderate pain. ... . 5 – Moderately strong pain.. |
