Pain 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:
- The site of the pain
- Whether there is presence of radiation or referred pain
- A description of the character of the pain
- The degree of pain
- The onset, frequency, and duration of the pain
- Causative, aggravating, and alleviating factors in the pain experience
- Interventions taken to treat the pain and the response to these interventions
- Adverse effects of the interventions taken to treat pain AND
- Any associated observations
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:
“The patient reports severe pain in the right great toe radiating 5 inches on the medial aspect of the right foot.”
When documenting the description and character of the pain, use quotations from the patient if possible, for instance:
“The patient describes the pain as [quote] excruciating, continuous, sharp, burning pain.”
Typical pain descriptors include:
For the degree of pain, include the assessment tool utilized, for instance:
“The patient rates pain as 9 on the 1 to 10 numeric scale.”
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:
“The patient’s current episode of pain began at 5:30 a.m., but patient has had recurrent episodes for 5 years.”
Next, record the pain frequency. It’s especially important to document any change in pattern.
“Episodes of pain usually occur every five to six months, but the previous episode occurred two months ago.”
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.
“Over the last five years, the duration of episodes of pain has varied from one to two days to the current one to two weeks, with the duration slowly extending over time.”
Report any associated observations, both physical and emotional. For example,
“The site of pain is edematous, erythematous, and warm. The patient is grimacing and moaning on any movement of the right foot.”
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:
“Moving the foot and bearing weight causes a severe increase in pain.”
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 patient developed generalized itching but no rash within 20 minutes of receiving morphine. The MD was notified and diphenhydramine 50 mg by mouth was administered.”
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:
- On initiation: every 15 minutes until stable
- Every 30 minutes for one hour
- Every hour for the next 4 hours
- Every 2 hours for the next 6 hours AND
- Every 4 hours after dosage stabilizes
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.