Completing worksheet for instances in which pain reassessment NOT documented within 2 hrs. of pain intervention

1. Completing worksheet for instances in which pain reassessment NOT documented within 2 hrs. of pain intervention Plan of Care and Medication Administration Reports may contain documentation that can be used to justify absence of pain reassessment documentation on Pain Reassessment Audit Report • For patients who are still hospitalized (OR who have been discharged less than 48 hrs. ago), reports can be printed from HED • For patients who have been discharged longer than 48 hrs., the same reports are available from StarPanel. • The following slides show step-by-step directions on how to access and use these reports.

2. To find reports on CURRENT patients (or patients discharged within the past 48 hrs.): 1 From the desired patient’s record, click on Reports link in menu at top of screen. Select Transfer Reports Select Medication Administration Report and/or Plan of Care report. 2 1 To find recently discharged pts. in HED, scroll to bottom of patient list. They will NOT have a room number listed by their name.

3. Change the default date range to show the date range for the desired report Click “Send”. The report will print to the default HED printer for the device on which it is requested. Hint: CWSs on each unit are set up with a default printer – usually same as the orders printer– but not all AWSs are set up to print, so you may want to request this report from a CWS on your unit. 4 5

4. To print reports from StarPanel for patients discharged more than 48 hrs. ago: Enter MR # & click magnifying glass to select patient Click on AllDocuments Admissions are shown with “Inpt” and unit name (eg. 10N) boxed in light blue. Scroll down if necessary to find the admission. Plan of Care (Vu_plan_care) and Medication Admin Rpt. (Ps_mar) will be found with documents saved on the day of admission (NOT day of discharge). 1 2 3 4

5. Click on small diamond to left of the name of the reports you want to view. The diamond will turn red. Click on “Documents” in upper right corner of frame to open the documents menu. Click on “show” to display selected documents in the frame below. There will be one entry for each selected document. To open these PDF reports in a separate window, click the blue hyperlink for each report. 6 7 5 8

6. Med Admin Rpt. Plan of Care Rpt.

7. Plan of Care (vu_plan_care) Short Term Goal and Goal Status If a pain intervention was done between 02:40 and 04:49, this short term goal status “Met” would count as a pain reassessment Nursing Summary If pain intervention for shoulder pain done at 16:00 or later, this Nursing Summary that mentions pain being controlled by end of shift would count as a pain reassessment

8. Medication Admin Rpt (ps_mar) In this example, administration of a 2nd pain med (Hydromorphone) within 2 hrs. of a prior pain med (Percocet) would take the place of a reassessment following the initial Percocet dose. 23:30YXY2

9. Fever before Ibuprofen MAR Nursing Flowsheet • If no pain reassessment following Ibuprofen dose, check to see if it was given following a temp elevation. • Ibuprofen doses shown on StarPanel MAR • Temp shown on age-appropriate Nursing Flowsheet in StarPanel 102