ADEQUATELY ADDRESSING a patient's pain during hospitalization is a complex process of assessment, reassessment, and documentation. One community hospital employed methods such as peer chart review and audit and feedback at the system and unit levels to increase nursing pain documentation from 27% to 72% over a 9-month period.
When face-to-face communication isn't possible, healthcare team members rely largely upon the medical record for information about a patient's clinical status.1 A vital part of the medical record, nursing documentation includes any electronically produced or written information used to document a patient's progress, condition, needs, treatment, or care.2 Complete, accurate, and timely nursing documentation of information such as a patient's pain intensity level could improve patient responses to nursing interventions. Documentation of the essential elements of pain includes assessment of pain (score), its location, orientation to location (such as medial, lateral, proximal, and distal) as appropriate, and reassessment of the essential elements of pain and the patient's response to the intervention.3
Documentation of pain assessment, intervention, and reassessment is imperative for the appropriate treatment of hospitalized patients. Pain can increase length of stay and decrease mobility, quality of life, appetite, and sleep.4 Pain management is so vital that in 2001 The Joint Commission issued a directive requiring all accredited healthcare organizations to do the following:
- recognize patients' right to receive suitable pain assessment and reassessment
- document the information in a way that enables reassessment
- create policies that provide suitable guidelines for prescribing pain medication
- provide education for patients, families, and providers
- collect data to evaluate the success and suitability of pain management.5
Besides The Joint Commission directive, Medicare initiated reimbursement changes in 2012 based on complications, readmissions, and patient satisfaction, including satisfaction with pain management.6 Although vital to quality patient care, compliance with these directives has been difficult for many healthcare organizations.
These organizations are similar to living organisms—dynamic, nonlinear, imbalanced entities. Within these entities, adaptation and change are difficult due to the unpredictability of personal, organizational, and outside or regulatory influences and cultures.7 To adapt, healthcare organizations have discovered that process change needs to occur on multiple levels, with frontline staff participating—if not taking the lead—in making changes. Through their knowledge and skills, staff can assist in identifying problems and envisioning improvements.8 Such measures are needed to alter the climate and approach to pain assessment, reassessment, and documentation.
Deficiencies in documenting pain assessment and reassessment in our medical center were noted, and improvement in documentation was identified as an organizational priority. Baseline compliance with pain documentation on four medical-surgical units was low, with the cardiopulmonary unit demonstrating a 17% documentation rate. This article focuses on unit-level initiatives in the cardiopulmonary unit.
The purpose of this quality improvement (QI) project was to improve documentation and knowledge of pain assessment and reassessment. Due to the low initial documentation rate, a specific time-associated goal wasn't established. The organization set a 90% overall documentation goal.
Ethical issues. Because the project was conducted as a QI initiative, institutional review board approval wasn't requested. Completed project documents containing limited patient information were placed in an envelope and given to the quality improvement RN (QIRN) after completion by staff. The QIRN kept all project documents in a locked office until they were hand delivered to the department of quality and patient safety for scanning into a database. After scanning, the documents were kept in a locked drawer and then destroyed at the completion of the project. The password-protected database was accessible to quality and patient safety staff only.
Setting. The project was conducted in a multispecialty community hospital serving a largely rural area of the Midwest with a population of about 535,000. The 325-bed teaching hospital is a tertiary referral center averaging over 13,000 inpatient admissions annually.
Planning the intervention. In the past, improvement measures had been aimed at a single process or component, with the assumption that once information or knowledge has been dispensed, staff members would change their behavior to adapt to the new guidelines or information given. A single-process approach doesn't take into consideration the complex and unique characteristics of a system and may not be effective in changing behavior.9 For these reasons, our organization implemented both system- and unit-level processes to increase pain documentation. (See System- and unit-level initiatives to increase pain documentation.)
System-level initiatives. The importance of adequate documentation was emphasized at the system level in “Tuesday education” sessions developed by the department of nursing held weekly in February 2010. Crucial components of this education included elements of a comprehensive pain assessment; documentation of pain assessment and reassessment, including what, where, when, and how to document; and review of the standard operating procedure. All medical-surgical RNs were required to complete an educational session, either by attending in person or by viewing a videotaped session.
Audit and feedback methodology has demonstrated a modest yet notably favorable effect on quality outcomes. The effectiveness of audit and feedback is enhanced if feedback is specific, frequent, and in writing.10
Our department of quality and patient safety developed an electronic medical record (EMR) quality audit tool for retrospectively monitoring administration of pain medications and documentation of pain assessment and reassessment. Audit schedules were rotated weekly to ensure that documentation from all shifts and days of the week was assessed. The EMRs of the first 10 patients listed on the admission/transfer unit report were reviewed, with attention to such elements as the number of oral medications and nonpharmacologic interventions administered for pain. (Oral medications were the focus of this project.) Each intervention was evaluated for reassessment of pain rating, location, and orientation, and was noted on the audit form. Once complete, audit forms were scanned into a password-protected database for interpretation.
Feedback about the audit results was delivered to staff by the QIRN, either in person or via e-mail, and included specific examples of documentation. Audits began February 28, 2010, and provided a baseline against which subsequent data could be compared.
The department of continuous readiness, which provides oversight of accreditations such as that of The Joint Commission, developed another audit method that employed a “tracer question” tool. The tool contained 10 questions about various topics, including pain, related to The Joint Commission system readiness. Ten staff members representing each shift were queried by the QIRN during March and April 2010. The goal of these queries was to increase knowledge and identify staff members who needed additional information related to pain assessment and reassessment. Also in April 2010, the EMR electronic flow sheet was reviewed and revised for ease of documenting and functionality, and to reflect a more cohesive documentation process.
Manager care reviews were implemented before the launch of the February 2010 pain initiative. In these reviews, clinical managers discussed critical elements of documentation with staff members. A patient's EMR was appraised using care review criteria to determine whether the patient's RN was meeting specific documentation criteria. In May 2010, point-in-time pain documentation was added to the care review criteria, providing specific examples and feedback to the frontline RN.
Unit-level initiatives. A QIRN was assigned to each medical-surgical unit and partnered with unit leaders, such as the manager, educator, clinical nurse specialist (CNS), and a member of the unit practice education and quality (UPEQ) committee to increase pain documentation and ensure the initiatives set forth by the organization were fully operational at the unit level.
The cardiopulmonary UPEQ committee consisted of clinical nurses representing all shifts, the clinical manager, nurse educator, CNS, and QIRN. The committee identified three strategies to improve pain documentation:
- Remind staff to document essential information in a timely manner.
- Ensure that everyone in the unit accepts responsibility for delivering superior patient- and family-centered care.
- Increase knowledge of and compliance with essential pain documentation.
A smaller task force consisting of two clinical nurses, the QIRN, and clinical manager was established to devise avenues to address these strategies. The task force developed an acronym, PAIN, to address the first strategy:
This phrase was printed on bright yellow strips of paper and attached to each computer in patient rooms, hallways, and the nursing station. This visual cue prompted staff to complete the needed documentation.
The second strategy was addressed by task force members during the April 2010 staff meeting. They led a discussion about all staff taking responsibility for addressing patients' pain. From the health unit coordinator (HUC) to the certified nursing assistant (CNA) to the RN, patient-centered care dictates that “every patient is my patient,” and anyone can assist in addressing pain. A graphic depicting the patient at the center of care with the HUC, CNA, and RN interacting around the patient was presented at the staff meeting. The graphic was also posted on the staff education board as a reminder.
The third strategy was addressed with two interventions: case review and peer chart review. Case review was initiated at the monthly staff meeting by first reviewing the documentation criteria in the standard operating procedure, including assessment and reassessment of pharmacologic and nonpharmacologic interventions. Then the EMRs of several coronary artery bypass graft surgery patients were reviewed. Through these case reviews, staff members saw how they'd documented the pain assessment, intervention, and reassessment in the EMRs of patients they'd cared for. Informal conversations with cardiopulmonary staff after the meeting indicated that they were surprised at the lack of reassessment, but after seeing specific examples they understood the expectations and need for better documentation.
Peer review of charts has been noted in the literature as a technique to increase nursing documentation. Peer chart review has been shown to identify items such as what's been documented correctly, what hasn't been documented, learning needs of staff, and quality of documentation.2 Elements for review can include care given, as well as appropriate documentation of that care from a colleague's perspective.11 Social pressure from peers can affect documentation, as demonstrated through a study that found when the first-shift nurse documented thoroughly, those on the following shift(s) would document thoroughly as well.2
The tool employed in the cardiopulmonary peer chart review had three sections. The first section stated the purpose of peer review and directions for completion. The second section was the scan sheet for a peer chart review, which consisted of 11 yes/no questions and 3 free-text questions, along with a comment box. The third section was a peer chart review reference tool consisting of information and screen shots regarding methods to find and document information within the EMR. Together, these sections gave nurses the information they needed to complete a peer chart review.
By completing the review, nurses learned what documentation was expected and where and how to document pain assessment and reassessment. Social pressure from peers evaluating documentation also encouraged more complete documentation.
Each RN on the cardiopulmonary unit had 4 weeks in which to review the documentation of two RN colleagues. One tool was used for each review and then placed in an envelope marked “confidential.” Nurses completed the tool during scheduled work hours. Some barriers to completing the audit included the time required to complete the tool, difficulty of finding time during a shift to complete it, and willingness of clinical nurses to participate in the audit.
Evaluation and analysis
Retrospective quality audits, a system-level initiative, occurred throughout the 9-month period, except during the peer medical record review. Retrospective audit methodology included EMR review using the data collection tool. Once complete, data collection tools were scanned into a database for analysis and exported to a spreadsheet for data display.
Run charts were developed and run chart rules applied using the median as the measure of central tendency. Run charts help to identify common and special cause variation, and have their own rules to identify the variation.
Percent of change was determined for each portion of the retrospective review process that demonstrated change. Run chart rules were applied to the data points, and the resulting figure was annotated to indicate when initiatives were instituted. (See Composite scores for selected interventions for pain.) The number of medications reviewed is listed at the bottom of the figure above the date. The sample size, or number of medications reviewed, varied greatly due to the variation in the number of admissions and discharges to the unit. For example, only two medications were reviewed on June 27. A limitation of these data is the inconsistent sample size of each run in the chart.
The peer chart review audit tool, a unit-level initiative, was managed in the same manner as the retrospective audit tool. Scan sheets were uploaded into a database and data exported into a spreadsheet for interpretation. The staff completion rate for peer chart reviews was 85%, excluding RNs on maternity leave and on-call staff. Of the charts reviewed, 46 involved administration of an oral medication. Of these 46 charts, 27 (58.7%) included a reassessment documented within 1 hour of administration and 19 (41.3%) didn't.
Respondent answers to free-text questions revealed several themes:
- Reassessing pain, including location and orientation, is important.
- The pain scale for patients with dementia wasn't well known.
- Some respondents thought that reassessment documentation was done well, but others believed that staff needed to do a better job.
- Using the tool was time-consuming.
Outcomes. Baseline documentation of pain assessment and reassessment on the cardiopulmonary unit was 17%. After the system-wide initiative of Tuesday education, documentation decreased to 10%, a decline for which we have no explanation. With unit tracer questions added from February to March, the median increased to 27%, establishing a process. Adding visual cues, manager care review, and staff meeting case review demonstrated an increase in the median to 56%. The combination of these system- and unit-level changes was increasing documentation; however, the increase didn't yet meet the organization's goal.
Peer chart review was initiated over a 4-week period from July 14 to August 13, 2010. After peer chart review, the median score of pain documentation increased from 56% to 72%. In the course of 9 months, documentation of pain assessment and reassessment for oral medications and nonpharmacologic interventions increased from a median of 27% to 72%.
Efforts to improve documentation of pain assessment and reassessment consisted of multilevel quality initiatives. Peer chart review, a unit-level initiative, demonstrated a notable increase in documentation of pain. Participating in a peer chart review was a new experience for many nurses on the unit. Anecdotal evidence from RNs on the cardiopulmonary unit suggests that the audit experience and findings led to positive staff views related to the need for consistent documentation. Gordon also found that a combination of strategies including persistent audit and feedback were required to raise documentation and effectiveness of pain management.5 Nurses should be encouraged to value their documentation of nursing care because it provides an effective way to define and evaluate professional nursing practice, such as pain assessment and reassessment.3
Our organization had the opportunity to further investigate the management of patients' pain through participation in a national study, the Pain Care Quality Study. Best practices, based on the results of this study, were selected for inclusion in the study's Pain Care Quality Toolkit. Recognized as a key strategy to improve nurse documentation of pain, our peer chart review tool was included in the toolkit. (See Toolkit links.)
Because the QIRN for this unit accepted a different position within the organization, use of the peer chart review tool wasn't continued as a unit initiative to raise documentation. Over the next 2 years, competing organizational priorities decreased the emphasis on pain documentation. Without focused pain documentation interventions, the cardiopulmonary unit and the overall organizational documentation rates, which had also increased, weren't sustained. Due to this decrease, interest in increasing documentation has been renewed.
Based on the past performance of the unit peer chart review tool, a modified tool consisting of four yes/no questions has recently been introduced throughout the organization. The new tool is shorter, easier to complete, and less time-consuming. The goal of this new tool is to increase pain documentation at the system level, not just the unit level. Data continue to be gathered at the system level, with ongoing evaluation of the new tool.
Nursing documentation of pain provides valuable knowledge to all members of the healthcare team and includes a complex process of assessment, reassessment, and documentation. Educational initiatives at the system and unit levels dramatically increased pain documentation on the cardiopulmonary unit. Use of frontline RNs as members of the unit-level task force and peer chart review initiatives assisted in engagement of staff and increased pain documentation.
Peer chart review has received limited attention in the literature as a QI strategy, but its implementation in this project resulted in a notable increase in documentation. The peer chart review tool used in the cardiopulmonary unit was identified as a key strategy to improve nurse documentation of pain assessment and reassessment. This strategy was so effective that the organization recently initiated a system-level peer chart review process to reinforce and raise documentation rates.
Institute of Medicine, Initiative on the Future of Nursing, Dissemination and Implementation of Evidence-Based Methods to Measure and Improve Pain Outcomes:
1. Dang VM, François P, Batailler P, et al. Medical record-keeping and patient perception of hospital care quality. Int J Health Care Qual Assur. 2014;27(6):531–543.
2. Wong FW. Chart audit: strategies to improve quality of nursing documentation. J Nurses Staff Dev. 2009;25(2):E1–E6.
3. Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract. 2010;16(2):112–124.
4. Eriksson K, Wikström L, Lindblad-Fridh M, Broström A. Using mode and maximum values from the Numeric Rating Scale when evaluating postoperative pain management and recovery. J Clin Nurs. 2013;22(5–6):638–647.
5. Gordon DB, Rees SM, McCausland MR, et al. Improving reassessment and documentation of pain management. Jt Comm J Qual Patient Saf. 2008;34(9):509–517.
6. Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res. 2014;472(8):2542–2549.
7. Rowe A, Hogarth A. Use of complex adaptive systems metaphor to achieve professional and organizational change. J Adv Nurs. 2005;51(4):396–405.
8. Kerridge J. Leading change: 1—identifying the issue. Nurs Times. 2012;108(4):12–15.
9. Murphy-Smith M, Meyer B, Hitt J, Taylor-Seehafer MA, Tyler DO. Put Prevention into Practice implementation model: translating practice into theory. J Public Health Manag Pract. 2004;10(2):109–115.
10. Hysong SJ. Meta-analysis: audit and feedback features impact effectiveness on care quality. Med Care. 2009;47(3):356–363.
11. Davis EO. Establishing a nurse-managed health center: assuring excellence. Nurse Pract Forum. 1993;4(3):151–157.
Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass/Wiley; 2009.