Worked a Number Years Office a Family

¶ … worked a number years office a family physician retired. You a position a busy surgical floor a local, acute-care hospital. You frequently hear references JCAHO requirements documenting a patient's pain assessment treatment, documenting medication administration, documenting verbal telephone orders. Documenting patient's pain assessment and treatment Pain assessment is the first step in managing pain. The suggested method of improving pain care essentially requires that the following procedures are followed properly and meticulously. a) The pain and its intensity must be measured using an appropriate tool.

There are many tools but the best is self reporting by the patient for the pain. b) The second important thing to be followed is to repeat the assessment consistently and record the same at varying intervals to record the process of the progress of pain. The tool or format for this must be chosen before hand and the same record structure must be maintained throughout.

c) It is also necessary in many cases where the patients may not be communicative to be aware of other signs of communications of pain, like crying, shouting and facial expressions and movements. These have to be noticed by the care giver and interpreted in terms of the patients pain experiences. d) The family and other members must be encouraged to participate in the pain assessment program and this will help bring out the individual characteristic and behavior of the patient.

Lastly the nurse or the treatment provider must ensure that they are qualified and capable for administrating to the patient without fail. (Norris, 2005) 2. Documenting medication administration One of the important methods of administration of medicine is the medication reconciliation. This follows a three step process and they are: a) Verification -- where the medications lists are collected, compared and analyzed and data created for the analysis. In other words the medications are verified in the first stage.

b) Clarification-- In this a system or data base is involved where the doctors, caregivers and the person associated with the medicines have complete clarity as to its delivery and appropriateness which is accessible and clear to all parties, the documentation becomes perfect at this stage and is clear.

c) Reconciliation is the on going and third step where the changes made to the medication levels, time and its benefits or remarks are added to the data and is available to all concerned in such a way that the course of medication for the patient is clear and the data is updated and modified with the passage of time and administration. These are the essential steps to administrate medicine to the patient.

(Aspden, Institute of Medicine (U.S.) Committee on Identifying and Preventing Medication Errors, 2007) d) Lastly simple error avoidance are brought about by verifying the quality and quantity of medicines administered and verifying the expiry date and the quality of the medicine and recording the same. (Joint Commission Resources, 2004) 3. Documenting verbal telephone orders The first thing to be noted is to insist on patient identification. Thus there must be identification at registration.

The telephone speaker must also record the new ID with name, date of birth, medical record number, and date of birth as identifiers. There must be a document with the name of the caller and the time of the call which is a computerized documentation system. All oral or telephone order, must be written down and read back verbatim to the prescriber, who should confirm the order's accuracy. Appropriate data must then be sent to the concerned data pool or the next follow up process. (Pettinicchi, 2005) 4.

Opinion on JCAHO's role regarding its documentation requirements to which accredited facilities must comply? There have been incidents where patient was harmed on account of the health delivery systems that were caused by errors. That is why the national patient-safety goals from the Joint Commission on Accreditation of Healthcare Organizations -- JCAHO have devised the methods to achieve safety goals. Some of the features include the.