Improving Documentation of Pain and PRN Reassessment
Project Description: "A reassessment of the patientÕs response must be documented within one hour of administration of a prn medication for pain or another indication (e.g. nausea, etc.). Historically, a staff nurse reviewed 5 medical records/week to assess compliance in the Pediatric Intensive Care Unit (PICU). Documentation compliance averaged 63% (range 32% - 100%) March 2014 Ð June 2015. Various passive efforts to provide education and reinforcement of documentation requirements did not improve compliance. The hospital received a requirement for improvement (RFI) related to reassessment after The Joint Commission visit July 2015. The PICU then implemented additional, more active, strategies to improve documentation compliance."
UF Health Big Aims: Reduce Variation None
MeSH Keywords: Documentation, Pain Management, Medication