Documented assessments and treatments of patients seeking emergency care because of pain.
OBJECTIVE
Pain is one of the most frequent symptoms for which people seek emergency care. Studies show that pain management in emergency clinics is insufficient. No previous studies regarding pain documentation at emergency clinics in the Nordic countries have been undertaken.


OBJECTIVE
The main purpose was to investigate the extent to which pain assessment, pain treatment and pain relief were documented in patient records.


METHODS
Patient records were reviewed using a study-specific protocol.


METHODS
Emergency unit at a Swedish university hospital.


METHODS
A total of 698 patient records randomly selected were reviewed using a study-specific protocol. According to Swedish law and the university hospital's quality and safety guidelines, there should be a note in each patient record regarding whether or not the patient was in pain on arrival. The guideline stresses the importance of using patient self-assessment by a visual analogue scale (VAS).


RESULTS
In 361/698 (52%) records, there was a note by a doctor or a nurse as to whether or not the patient had been experiencing pain on arrival. In 319 of these 361 records (88%), a full pain assessment had been documented. In 15/319 (5%) cases, the pain assessment included patient VAS assessment. In 54/319 (17%) patient records, a note regarding pain treatment was found. Significantly more notes regarding pain treatment were found in the records with an initial documented pain assessment, when compared with the records without any such assessment (p < 0.01). In the 54 records with notes regarding pain treatment, 10 (19%) included documentation regarding the effect of the treatment.


CONCLUSIONS
The results show an alarming lack of documentation regarding pain assessments, pain treatments and follow-ups. This is in marked contrast to Swedish law, which clearly stipulates the responsibility of health care staff to document information relevant to providing safe care. Prompt action to improve pain documentation is warranted.
Lewén
Hanna
H
The Emergency Department, Karolinska University Hospital, Solna, Sweden. hanna.lewen@karolinska.se
Gardulf
Ann
A
Nilsson
Jan
J
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D006785:Hospitals, University; D006801:Humans; D008875:Middle Aged; D059408:Pain Management; D013548:Sweden; D055815:Young Adult