Hi everyone,
Every Wednesday morning I do chart audits in both units. One nursing assessment I am auditing is pain assessments/reassessments- and we could use some improvement. According to policy https://www.musc.edu/medcenter/policy/Med/C064.pdf you MUST perform a pain reassessment within one hour of pharmacologic intervention, and this must be documented by the end of your shift. This applies to BOTH scheduled and PRN medications per policy. In PICU, the easiest way to ensure compliance is to document a pain assessment with your hourly vital signs- then you are always covered. 7C- when you scan your pain med, you can document a pain assessment on the same screen (see me if you have questions), you just need to remember to do the follow-up assessment. In addition to following policy, this documentation helps the team determine if current therapies are effective.
Also, as I've been auditing pain meds, I have noticed MANY high-alert meds without co-signatures. It is the responsibility of the nurse administering the medication to be sure it gets co-signed. Please check your documentation before leaving at the end of the shift- we all know- if it wasn't documented, it wasn't done.
See me with questions, thanks everyone!
Erin
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