¶ … 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...
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