Assessing Adherence to Pain Medication Reassessment and Documentation Using Timed Visual Reminders
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Abstract
Problem & Purpose: In the fiscal year 2022, the completion of pain reassessment documentation was 38% of all oral pain medication administration at the current clinical site, a Neuro Intermediate Care Unit (Neuro IMC) at a large tertiary care hospital. Published evidence shows that timed visual reminders in the electronic health record (EHR) and standardized staff education increase the frequency of timely pain reassessment. This project aimed to improve the rate of pain reassessment and documentation within 60 minutes after PRN oral pain medication administration to 100% by using timed visual reminders within EPIC over 15 weeks in fall 2023 on the Neuro IMC. Methods: Timed visual reminders in EPIC automatically pop up after pain medication administration. The project leader (PL) promoted staff RN adherence by obtaining formal written commitments from key partners, preparing champions and shift huddles, sharing weekly chart audits, and setting up online and in-person educational sessions. The PL performed weekly chart audits, entered data (medical record number [MRN], completion of pain reassessment documentation within 60 minutes) into REDcap, a HIPAA-compliant database, and surveyed staff RNs each month regarding response to a visual reminder tool within EPIC. The PL transformed these data into run charts to identify patterns over the 15 weeks. Results: The project measured the number of times nurses completed pain reassessment within 60 min per total number of times nurses gave oral pain medications. RNs completed 928 oral pain medication administrations. Seventy pain reassessment documentation occurred for another purpose or inadequate timing and were eliminated. Pain reassessment documentation within 60 minutes of administration by RNs occurred for 75.3% of all oral pain medication administration. Conclusions: Timed visual reminders within EPIC improved pain reassessment and timeliness of documentation rate from 38% to 75.3%.