How Well Do Physicians Document Pain?

1. How Well Do Physicians Document Pain?

2. Edward P. Sloan, MD, MPH Stephen C. Eder, MS, MPH Knox Todd, MD, MPH

3. Departments of Emergency Medicine University of Illinois at Chicago Emory University

4. Introduction:Clinical Issues • Acute pain Rx is key EM objective • JCAHO uses pain Rx as one quality marker • How well are physicians and nurses documenting patients pain in the ED? • Are JCAHO requirements for pain documentation on charts being met?

5. Introduction:Study Questions • How often do physicians document pts. pain? • How often do nurses document pts. pain? • Are there differences in how often pain is documented by nurses and physicians? • Is the degree of a patient’s pain documented? • Are pain scales used to document pain? • What factors determine why pain is documented more often?

6. Methods:Study Sites, Available Charts • Urban ED at a University Hospital • 302 patients surveyed regarding their pain • 261 complete charts (86%) available for review • Triage note • Nurses note • Resident note • Attending note • 290 Resident + Attending notes available (96%) • 271 Triage + Nurses notes available (90%)

7. Methods:Study Design • Pain assessments categorized into 3 time points • Initial pain assessments • Subsequent pain assessments (after therapy) • Pain assessments at discharge • Documentation hierarchy recorded • Pain Scale (1-10) • None/Mild/Moderate/Severe • Better/Worse/Same • Degree of pain written on chart • “Pain” written on chart

8. Results:Initial Pain Assessments • Physicians (290 charts) • 90% recorded an initial pain assessment • 10% used some form of pain scale • Nurses (272 charts) • 84% recorded an initial pain assessment • 14% used some form of pain scale • Total = N + P (261 charts) • 94% recorded an initial pain assessment • 14% used some form of pain scale

9. Results:Initial Pain Assessments Nearly all complete charts had some form of initial pain assessment.

10. Results:Initial Pain Assessments: MD vs. RN Nurses Physicians Physicians document initial pain assessments more often than nurses, but are less likely to use a pain scale.

11. Results:Subsequent Pain Assessments • Physicians (290 charts) • 15% recorded a subsequent pain assess. • 14% used some form of pain scale • Nurses (272 charts) • 25% recorded a subsequent pain assess. • 24% used some form of pain scale • Total = N + P (261 charts) • 35% recorded a subsequent pain assess. • 33% used some form of pain scale

12. Results:Subsequent Pain Assessments Physicians and nurses do not often record subsequent pain assessments.

13. Results:Subsequent Pain Assessments: MD vs. RN Nurses Physicians Nurses document subsequent pain assessments more often than physicians.

14. Results:Discharge Pain Assessments • Physicians (290 charts) • 1% recorded a discharge pain assess. • 1% used some form of pain scale • Nurses (272 charts) • 6% recorded a discharge pain assess. • 5% used some form of pain scale • Total = N + P (261 charts) • 8% recorded a discharge pain assess. • 7% used some form of pain scale

15. Results:Discharge Pain Assessments Discharge assessments are rare.

16. Results:Discharge Pain Assessments: MD vs. RN Nurses Physicians Nurses document discharge assessments more often than physicians.

17. Results:Documentation: MD vs. RN PhysiciansNursesp-value Initial 90.9% 83.8 % p = .04 Subsequent 15.2% 25.4% p = .004 Discharge 1.0% 6.3% p = .002

18. Results:Pain Assessment Predictors • Patients initially in severe pain • 2x more likely for subsequent assessments • 66% vs. 34%, p = .03 • Patients receiving IV analgesics • 2x more likely for subsequent assessments • 61% vs. 26%, p < .001

19. Conclusions:Overall Pain Documentation • Pain assessments occur most often initially • MDs, RNs do not tend to use pain scales • Subsequent pain assessments more likely: • Patients in severe pain on arrival • Patients who are given IV narcotics • Discharge pain assessments are rare

20. Recommendations:ED Pain, Rx Documentation • More systematic documentation is needed before and after treatment • Need to document pain at discharge • Need to document subsequent pain in high risk patients