A comparison of observed versus documented physician assessment and treatment of pain: the physician record does not reflect the reality.
OBJECTIVE
The Joint Commission requires "appropriate assessment" of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record.


METHODS
This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered, and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an "ergonomic study" without knowing the exact nature of data collection, and patients released their records.


RESULTS
The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time.


CONCLUSIONS
Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.
Chisholm
Carey D
CD
Department of Emergency Medicine, Division of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA. cchisholm@clarian.org
Weaver
Christopher S
CS
Whenmouth
Laura F
LF
Giles
Beverly
B
Brizendine
Edward J
EJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D000700:Analgesics / Q000008:administration & dosage*; D002648:Child; D004282:Documentation; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records / Q000706:statistics & numerical data*; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy*; D010147:Pain Measurement / Q000706:statistics & numerical data*; D010819:Physician's Role; D010817:Physician-Patient Relations; D014193:Trauma Centers / Q000706:statistics & numerical data
D000700:Analgesics