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Nursing home chart audit forms

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nursing home chart audit formsnursing home chart audit formsnursing home chart audit forms
Pain audit tools
Dear Colleague:We appreciate your interest in the Pain Audit Tools developed and used at the City of HopeMedical Center.

Attached for your information and use are three examples.Example 1 is the Chart Audit Form.

A few comments about the items are:1.Item 3 identifies disease status based on our oncology population.

You may want tomodify this to represent different patient groups in your setting.2.Items 8 & 9 identify how pain is currently charted.

For example, you might note thatAthe physician states pain is mild; evening nurse states that pain is better.

Norecordings on days or evening shifts.Items 10 and 11 refer to follow-up evaluation.

This is particularly useful since JCAHOlooks at evaluation very closely.Example 2 is the Patient Interview Component of the audit.

You may also need to modify thisform based on your patient population.

We have found item 14 to be particularly helpful whencompared to item 7 of the chart review form so that we can contrast what medication and dose isordered for the patient versus what they are actually taking.

In each of these audits we have found thatthe patients are consuming only a fraction, generally approximately 50%, of the medicines that areprescribed.

This points to our need to improve compliance with medications already available inaddition to ordering more appropriate medications.Example 3 is a chart review form that was developed specifically for our Surgical Service.

Wehave designated some specific surgeries to be reviewed.

You may want to modify this based on thesurgical procedures that you are interested in.

This form serves as an example of modifying the audit tomeet specific areas or needs.-2-You may also find the following articles useful in your efforts to conduct pain audits:Betty Ferrell, Cheryl Wisdom, Michelle Rhiner, and Joseph Alletto.

Pain managementas a quality of care outcome.Journal of Nursing Quality Assurance, 1991; 5(2):50-Betty Ferrell, Margo McCaffery, and Rebecca Ropchan.Pain Management as aClinical Challenge for Nursing Administration.Nursing Outlook, 1992:40(6); 263-268.You may also wish to contact the American Pain Society for their QA

guidelines (5700 OldOrchard Road, First Floor, Skokie IL

60077-1057, 708/966-5595).We hope that these forms are useful to you.

We have found auditing charts and doing patientinterviews is a very important component of quality assurance to improve pain management.

We lookforward to hearing about your efforts.Sincerely,Betty R.Ferrell, RN, PhD, FAANResearch ScientistNursing Research and Education2/98CHART AUDIT
Subject #
Medical Record #
Interviewer Initials
1.Patient Setting/Unit
2.Patient Diagnosis
3.Disease Status:
Cancer/Active Treatment
Cancer/Palliative Care
Other than cancer
4.Current Treatments

Other (List)
5
nursing home chart audit forms
.Reason for Admission/Visit
6.Admitting Medical Service
Chart Review 7.What is currently prescribed for the patient's pain?MedicationWhen StartedDoseChart AuditPage 2 8.Is there evidence of use of objective ratings (i.e.visual analogues, rating scales, pain tools)?
(If yes identify both the rater and rating, example:

"0-5 rating scale in nurse's notes") 9.Documented descriptions of pain other than objective ratings for the previous 24-hour period.

If present, specify rater and progress report says "Painbetter.")Has a follow-up evaluation been charted Modalities
Yes No11.Is pain assessment reflected in:RN Notes-Last 24 Hrs

Yes

NoRN Care Plan:
Yes

No
MD H&P
Yes

NoLast MD Progress PAIN INTERVIEWYour comfort is very important to us.

We would appreciate your input on the following survey so that we might learn how to better relieve your pain.

Youranswers to this survey will remain confidential.

Your participation is completely voluntary.1.Your Age
2.
Male
Female 3.Your Diagnosis
4.When was your cancer first diagnosed?
Month
Year 5.When did your pain first begin?
Month
Year 6.Who writes the prescriptions for your pain medications?

(List doctors' names)

Please answer the following questions by circling the one numberon each line that best describes your pain or other symptoms.7.How much pain do you have right now?

No Pain Pain As Bad As
You Can Imagine 8.Over the past 24 hours, what is the average amount of pain you have had?0
1
2
3
4
5
6
7
8
9
10

No Pain Pain As Bad As
You Can Imagine 9.What is the worst amount of pain you have had in the last week?0
1
2
3
4
5
6
7
8
9
10

No Pain Pain As Bad As
You Can Imagine10.Do you have a problem with constipation?0
1
2
3
4
5
6
7
8
9
10

No Problem
Severe Problem

11.Do you have nausea?0
1
2
3
4
5
6
7
8
9
10
All the TimePatient Pain InterviewPage 212.Do you have a problem with drowsiness or sleepiness from your medication?0
1
2
3
4
5
6
7
8
9
10
All the Time13.How satisfied are you overall with the current treatment you are receiving for your pain?0
1
2
3
4
5
6
7
8
9
10

Not AtVery SatisfiedAll Satisfied14.What medicines are you taking for pain?

Please list.Name of MedicineHow Much Is OrderedHow Much Have YouTaken In Last 24 Hours15.Which of the following influence or interfere with your pain management?

(Check all that apply.)
Money to pay for pain medications.
Communicating or explaining your pain to others.
Coming in to pick up prescriptions.
Being afraid of being addicted to pain medicines.
Side effects of pain medicine.
Concern that I should save some pain medicine in case my pain gets worse.
Other (Describe)
16.Ar
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