Timed Reminders within the Electronic Health Record to Improve Pain Reassessment Documentation

Abstract

Problem & Purpose: Ineffective reassessment and documentation of a patient’s pain level can lead to physical and psychosocial impairments compromising the ability to participate in milieu activities among psychiatric inpatients. In a large community hospital’s inpatient psychiatric unit, pain reassessments were only completed 57% of the time. The purpose of this quality improvement project was to implement modifications to the pain assessment flowsheets in the electronic health record on an adult inpatient psychiatric unit to improve nurse adherence to reassessment and documentation of pain scores. Methods: Pain reassessment timed reminders were added into the electronic health record flowsheets and tracked over a 13-week period on an inpatient psychiatric unit in a large community hospital. An algorithm of the unit’s pain management policy was developed laying out step by step guidance for pain reassessment timelines and medication management. Twenty staff nurses from a unit with a 19-bed patient capacity participated in this quality improvement project. Nurses received education on how to add timed reminders into the electronic health record flowsheets prior to project implementation. Pre and post implementation surveys were administered to evaluate how often nurses reassess and document pain levels within the appropriate timeframe. Weekly run charts were used to analyze and track data on nursing staff compliance rates. Results: Data collected in the weekly audits reflected a 20% improvement in pain reassessment overall at the conclusion of the project timeline. A displayed pain assessment algorithm helped to boost reassessment documentation rates by 10% initially. The next week reassessment documentation decreased by 22% after posting names of individual nursing staff adherence rates. Documentation adherence rates increased within two weeks by 20% after posting a certificate of achievement displaying nursing staff achieving 100% weekly pain reassessment documentation. Conclusion: The use of timed reminders embedded into electronic health record flowsheets, a pain management algorithm, and recognition of staff with 100% documentation compliance contributed to improvement in pain reassessment documentation practices. Implications for practice included timely documentation of pain reassessments improving pain management among psychiatric inpatients.