King, Nimotalahi2025-05-122025-05-122025-05https://archive.hshsl.umaryland.edu/handle/10713/23515Problem: An observed deficiency of adherence to required pain evaluation protocols exists within the oncology unit of a mid-size community hospital. In December 2023, five percent of audited charts were missing initial pain assessment documentation, and 43% were missing a reassessment. In January 2024, 24% of charts were missing pain reassessment documentation. Forty-nine registered nurses were expected to be impacted by the implementation of this quality improvement initiative. Approximately 2,000 patients yearly were expected to benefit from this initiative due to improved pain assessment and documentation. Purpose: The purpose of this quality improvement project was to improve documentation of pain assessment and re-assessment among bedside nurses working on the oncology unit by implementing and measuring the use of visual reminders, chart audits, and feedback, which are an evidence-based, research-supported practice change. Methods: This initiative was implemented over 15 weeks in the Fall of 2024. On the first week, staff received education and visual aids were posted on all nursing workstations and patient rooms. Staff completed a REDCap survey using a QR code to indicate receipt of educational material. Every week, the project lead (PL) reviewed all patient charts and emailed feedback. Results: Following project implementation, the percentage of patients with a documented shift pain assessment ranged from 88.9% to 100% with a median of 95.5%. Similarly, pain reassessment documentation ranged from 25% to 85.7% with a median of 55%. Conclusions: Findings suggest that the percent documentation values improved compared to pre-implementation data. An additional strategy that could improve documentation is the implementation of an automatic electronic pain documentation reminder system that would automatically populate when medication is scanned as administered.en-USPain MeasurementPain ManagementDocumentationNursing Staff, HospitalReminder SystemsDNP ProjectGayden, Johnny