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¶ … 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...
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…
References
Aspden, Philip; Institute of Medicine (U.S.) Committee on Identifying and Preventing
Medication Errors. (2007) "Preventing Medication Errors" The National Academies Press.
Joint Commission Resources. (2004) "A guide to JCAHO's medication management
standards" Joint Commission Resources.
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