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Final Summary Paper

Increasing Nurse Pain Assessment Charting Compliance by Implementing Random Chart

Audits with Supplemental Education

Megumi Miyajima-Olguin RN

Bon Secours Memorial College of Nursing

NUR 4242 Synthesis of Nursing Practice

Assistant Professor Trina Gardner, MSN, RN

10/29/2022

“I pledge…”
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Introduction

People typically make trips to the emergency room for pain related issues. This project

was implemented to monitor pain assessment charting in the emergency room setting through

randomized pain audits. Education was provided to emergency room nurses on hospital-wide,

pain policies and procedures. This was done in hopes of increasing nursing compliance with pain

assessment, charting, and monitoring while increasing patient safety with opioid administration.

Background

Pain is the most common reason for people to visit the ER (Motov et al., 2021). Pain

management is a large part of nursing practice and “...untreated pain is considered professional

misconduct or a violation of fundamental human rights” (Germossa et al., 2019). International

pain organizations have called for improvement “...in providing safe, effective, and timely pain

management” (Motov et al., 2021).

Proper, timely pain management has strong ties to patient satisfaction. Pain management

in the hospital setting is a category on the “Hospital Consumer Assessment of Healthcare

Providers (HCAHPS)”, and it may dictate if a hospital is reimbursed by Medicaid or Medicare.

“...The higher a hospital’s HCAHPS scores, the higher their reimbursements will be, and vice

versa” (Detwiler & Vaughn, 2022).

A 2019 study showed that a “...nurse-based pain management programme (in-service

education and rounding) significantly improved patient-reported pain intensity and interference”

(Germossa et al., 2019). The component of education and monitoring charting showed

significant improvement on patient’s perception of pain management.

Proper monitoring of pain is especially important as opioid pain medication has the side
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effects of sedation and respiratory depression. It is important to monitor and document the

effects of pain medication to see if it may be over sedating to patient or improving pain

symptoms.

With all the aforementioned things in mind, I created this small study. I am a charge

nurse at Richmond Community Hospital emergency department, and I also precept new hires and

new nurses. While precepting, some of the things I am responsible for are teaching nurses

required charting and familiarizing them with the policy and procedures. I noticed a large deficit

in pain assessment charting. My project mentor is Oriana Misegades, BSN, RN, and she is the

Clinical Care Lead (CCL) for Richmond Community Hospital Emergency Department.

Bon Secours “Pain Management Standards PF6110” (Bon Secours Mercy Health, 2021)

requires all patients to have an initial pain status charted with an appropriate pain scale. A pain

assessment must be done a minimum of once every 12 hours, and a reassessment must occur

within 1-hour post-intervention.

With opioids or other sedating pain medications, per the “Opioid Management PF3328”

policy, the nurse must monitor for sedation using the Pasero Opioid‐induced Sedation Scale

(POSS). An appropriate pain scale and POSS must be assessed before intervention and within 1

hour for oral opioids and within 15 minutes for IV opioid medications (Bon Secours Mercy

Health, 2021). Per policy, the nurse must document that opioid/sedating medication education

was given. Education includes: “...the purpose of the medication, common side effects, and signs

and symptoms of adverse reactions” (Bon Secours Mercy Health, 2021).

My mentor, Oriana, and I came up with a pain audit tool (See “Appendix”) that attempts

to capture the policy’s documentation requirements. Over the course of 3 weeks, I used the pain
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audit tool to check pain assessment and required charting of random patients. This project was

done to, hopefully, help increase compliance in assessing ER patient’s pain and monitoring pain

interventions effectiveness. Accomplishing this goal should improve medication safety for

emergency room patients as well as increase patient satisfaction. The hope is that nurses will be

more mindful of pain medication effects and monitoring for the interventions’ improvement of

pain.

Method
Over 3 weeks, there was a total of 24 pain audits performed on random nurses and

random patients that received pain medication interventions. I did 4 non-opioid pain medication

assessment/intentions and 4 opioid assessments/interventions each week (a total of 12 each). I

intended to start at least one shift a week with a huddle that included pain charting policy

education, but only did this during week 1 due to time constraints.

A pain audit tool was developed by myself and my mentor. We reviewed company Bon

Secours Mercy policies “Opioid Management PF3328” and “Pain Management Standards

PF6110”. We produced a 5-question slip (see Appendix).

Each audit came with immediate feedback. Depending on where the charting mistakes

were, policy education was provided to the audited nurse. We would also sit down and look at

each chart together. We would fix the chart at that time, if needed. If a nurse did well in and

audit, they were praised.

Results

After collecting all the pain audit data, I counted the responses and added them to the
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chart below:

Table 1

Pain Audit Totals

Week 1
Yes No N/A
Initial pain assessment (triage) 8 0 0
Full pain assessment prior to every pain med administration 4 4 0
-> Pain reassessed per hospital policy 5 3 0
POSS assessment prior to every narcotic administration 0 3 5
.opioid note for narcotic administration 1 2 5
Patient left prior to reassessment? 3 5 0
Total 21 17 10

Week 2
Yes No N/A
Initial pain assessment (triage) 8 0 0
Full pain assessment prior to every pain med administration 2 6 0
-> Pain reassessed per hospital policy 1 6 1
POSS assessment prior to every narcotic administration 2 3 3
.opioid note for narcotic administration 1 4 3
Patient left prior to reassessment? 0 1 7
14 20 14
Week 3
Yes No N/A
Initial pain assessment (triage) 8 0 0
Full pain assessment prior to every pain med administration 8 0 0
-> Pain reassessed per hospital policy 4 3 1
POSS assessment prior to every narcotic administration 4 0 4
.opioid note for narcotic administration 3 1 4
Patient left prior to reassessment? 6 2 0
Total 33 6 9

The main issue with figuring out the percentages was that some responses were N/A. In

those cases, I took the number of responses, not including ‘N/A’, and divided it by the number of

‘yes’ responses. Percentages of compliance were plotted on the graph below:

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Table 2

QI: Pain Audit Results

% Compliant

X-axis: QI: Pain Audit Results Legend

1 Initial pain assessment (triage)

2 Full pain assessment prior to every pain med administration

3 Pain reassessed per hospital policy

4 POSS assessment prior to every narcotic administration

5 .opioid note for narcotic administration

6 Patient left prior to reassessment?

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During week 1/3 of observation gathering, I noticed how many nurses do not chart pain

assessments when giving interventions. I also noticed that the POSS were not being used

and .opioid notes were only used half the time with sedating medication administration. Another

observation I noticed was how annoying my audits seemed. I did notice improvement by the end

of this week.

During week 2/3, I saw a significant drop in compliance from 50% in week 1 to 33% in

week 2. I noticed that there were a lot of travel nurses that week, but one was eager to learn and

even made it a game to try and chart perfectly. The other travel nurses got a little upset with

being corrected repeatedly. They expressed that they were busy and that they were doing pain

and opioid response assessments; just in their heads. I continued to be persistent and reeducated

them on the policies to the point of redundancy.

Week 3/3 showed 100% in full pain assessment prior to every pain med administration. A

lot of the nurses were aware of my study and trying to chart perfectly. There was a significant

increase in all assessment and charting areas.

My mentor and I discussed the findings and how to continue the positive trend through

future chart auditing and nurse education. I am planning on hanging the poster we will create

later in the semester in the nurse break room.

Conclusion

I learned a lot about compliance and accountability. I saw a significant increase in pain

assessment, charting, education, and reassessment from week 1 to week 3 of my project.

However, since my data collection has been over, I have been reviewing charts in my charge

position and am not seeing much compliance. It seems that nurses are more compliant when they
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know someone is looking over their shoulder. For ongoing pain assessment and charting

compliance, there may need to be regular chart auditing.

The educational portions of my study appeared to be helpful as a lot of nurses did not

know what they needed to chart. I am a firm believer in teaching good habits. When a nurse

starts on the floor, mandatory charting needs must be taught in orientation with greater emphasis.

This study has shown me a great deal about different nursing styles. Some nurses just like

to be in the room and do minimal charting. Some nurses are perfectionists with their patient care

and charting. Whatever type of nurse you are, you must meet compliance with charting for

liability purposes. In the case of pain management, a nurse should chart pain assessment, POSS,

opiate education, and pain reassessment. It tells the reader, whether it be the clinical care lead on

your unit or a judge in a courtroom, that you were thinking of these things and practicing safe

medicine.
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References

Bon Secours Mercy Health. (2021). Opioid management PF3328. Policy and Procedure.

Bon Secours Mercy Health. (2021). Pain management standards PF6110. Policy and Procedure.

Detwiler, K. & Vaughn, N. (2022). Patient satisfaction & HCAHPS reimbursement. Relias.

Accessed October 15, 2022 from https://www.relias.com/blog/how-do-patient-

satisfaction-scores-affect-reimbursement

Germossa, G.N., Hellesø, R. & Sjetne, I.S. (2019). Hospitalized patients’ pain experience before

and after the introduction of a nurse-based pain management programme: A separate

sample pre and post study. BMC Nurs 18, 40. https://doi.org/10.1186/s12912-019-0362-y

Motov, S. M., Vlasica, K., Middlebrook, I., & LaPietra, A. (2021). Pain management in the

emergency department: A clinical review. Clinical and Experimental Emergency

Medicine, 8(4), 268–278. https://doi.org/10.15441/ceem.21.161

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Appendix

Pain Audit Tool

RN: MRN:
Yes No N/A
Initial pain assessment
(triage)
Full pain assessment
prior to every pain med
administration

-> Pain reassessed per

hospital policy

POSS assessment prior

to every narcotic
administration

.opioid note for

narcotic administration
Patient left prior to
reassessment?

020