Pain assessments and the provision of analgesia: the effects of a templated chart.
OBJECTIVE
Many emergency departments (EDs) have incorporated pain assessment scales in the medical record to improve compliance with the requirements of the Joint Commission on Accreditation of Healthcare Organizations. The authors conducted a pre-post trial investigating the effects of introducing a templated chart on the documentation of pain assessments and the provision of analgesia to ED patients.


METHODS
A total of 2,379 charts were reviewed for inclusion based on the presence of a chief complaint related to trauma or nontraumatic pain, with 1,242 charts included in the analysis.


RESULTS
Baseline demographic characteristics, mechanism of injury, location of injury, and initial pain severity were similar in the two groups. The proportion of patients with documentation of pain assessment increased from 41% to 57% (p < 0.001). In particular, traumatic mechanisms and chest, abdominal, and extremity pain yielded the largest improvements in documentation after introduction of the templated charts. Documentation of pain descriptors also improved for time of onset, duration, timing, and context (p < 0.01). Pain control in the templated chart group, however, remained unchanged and the provision of analgesia in the ED was not altered, with the exception of nonsteroidal medications, which decreased from 46% to 36% (p < 0.01).


CONCLUSIONS
Although documentation is improved with a templated chart, this improvement did not translate into improved patient care.
Baumann
Brigitte M
BM
Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey--Robert Wood Johnson Medical School at Camden, Camden, NJ, USA. baumann-b@cooperhealth.edu
Holmes
John H
JH
Chansky
Michael E
ME
Levey
Helen
H
Kulkarni
Miriam
M
Boudreaux
Edwin D
ED
D000328:Adult; D000698:Analgesia / Q000592:standards / Q000706:statistics & numerical data*; D004282:Documentation / Q000379:methods* / Q000592:standards; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D010146:Pain / Q000517:prevention & control; D010147:Pain Measurement / Q000592:standards; D012189:Retrospective Studies