ONS Connections: Electronic medical record can remind nurses to document post-pain medication scores

PHOENIX—Using electronic medical records (EMR) to remind nurses to implement post-pain medication score documentation (PPMSD) ensures that the prescribed pain medication remains effective, according to research presented at the Oncology Nursing Society (ONS) Connections: Advancing Care Through Science conference.

Many cancer patients and their loved ones fear uncontrolled pain. Controlling pain provides for quality of life, and it is a priority for oncology nurses. Pain scores allow nurses to understand the effectiveness of pain medication, but the complexity of nursing care of oncology patients puts many competing demands on the nurse. Nurses are busy, and they have trouble remembering when to document, said study author Joanne Abbotoy, BSN, RN, during her presentation at ONS Connections 2012. These demands can result in incomplete documentation. Document reviews have found that PPMSD was consistently missing. Staff nurses assess the effectiveness of pain medication, but role strain and interruption during documentation lead to incomplete PPMSD.

These researchers collaborated with their EMR team to design a prompt so that, when the use of a pain medication is documented, a medical logic module generates a task in the electronic medication administration record. The task reminds nurses to record the PPMSD. The EMR has a link so the task can be marked by the nurse to document the pain score on the nursing assessment flow sheet. If the nurse does not mark the task, it becomes overdue and turns red. The nurse administrator can electronically review overdue task reports. Also, overdue tasks are automatically printed at the end of each shift to provide a final reminder to complete the task.

From October 2011 to most recently in 2012, nurse completion of pain score documentation increased from 80.7% compliance to 92% compliance, according to Abbotoy.

Completing PPMSD throughout a patient's hospitalization allows the nurse and all patient care providers to review and monitor the patient's response to pain medication. This review can occur in real time or over a period of time, and it ensures that the prescribed pain medication remains effective.

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