Was the patient pain level assessed and documented upon arrival to the unit/department?

ED/UC - Upon arrival in triage and upon arrival to the ED room.

Was there an intervention documented if the pain score was > comfort goal?

If a comfort goal is not documented, then the goal defaults to 0.

NPASS score of 3 or greater indicates pain is present.

Is there a pain reassessment documented within 60 minutes of the intervention?

A reassessment is required if there is an intervention for a pain score > comfort goal.

Reassessments can be medication and/or non-pharmacological interventions.

If the reassessment pain score remains above the comfort goal, then additional interventions and reassessments are required.

 

For ED/UC patients only... Is there a pain score documented within 1 hour of discharge?

Routine pain assessment is required in the ED/UC at discharge based on the patient's condition.

For inpatient units only... Is there an active Pain Plan of Care?

Pain plan of care is required to identify pain management strategies and outcome.

Document outcome each shift.

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