Pain Audit Tools (PAT)

Background:

Quality palliative care is important in ensuring the wellbeing of those suffering with a terminal illness. One of the primary roles of a palliative care-giver is to be able to make accurate pain assessments. Without sufficient training nurses will struggle to meet the many tough demands they meet. The Pain Audit Tools (PAT) are therefore useful in maintaining a high standard of care and allowing improvements to be made where necessary. It serves as both an educational tool and a quality assessment tool.

Author of Tool:

City of Hope Pain & Palliative Care Resource Center

Key references:

City of Hope Pain & Palliative Care Resource Center. Research Instruments/Resources. City of Hope Pain & Palliative Care Resource Center. Retrieved October 27, 2012, from https://prc.coh.org/res_inst.asp

Ferrell, B., Wisdom, C., Rhiner, M., and Alletto, J. (1991). Pain management as a quality of care outcome. Journal of Nursing Quality Assurance, 5(2), 50-58.

Ferrell, B, McCaffery, M., and Ropchan, R. (1992). Pain Management as a

Clinical Challenge for Nursing Administration. Nursing Outlook, 40(6), 263-268.

Primary use / Purpose:

The Pain Audit Tools (PAT) includes three separate surveys used for gathering information on pain management. The first is an 11-item audit form useful for obtaining basic information about the patient. The second is a 17-item, self-report, pain assessment to be filled out by the patient. Finally, the third survey is used for aiding surgical reviews.

Dear Colleague:

We appreciate your interest in the Pain Audit Tools developed and used at the City of Hope Medical 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 to modify this to represent different patient groups in your setting.
2. Items 8 & 9 identify how pain is currently charted. For example, you might note that
the physician states pain is mild; evening nurse states that pain is better. No recordings on days or evening shifts.
3. Items 10 and 11 refer to follow-up evaluation. This is particularly useful since JCAHO looks at evaluation very closely.
Example 2 is the Patient Interview Component of the audit. You may also need to modify this form based on your patient population. We have found item 14 to be particularly helpful when compared to item 7 of the chart review form so that we can contrast what medication and dose is ordered for the patient versus what they are actually taking. In each of these audits we have found that the patients are consuming only a fraction, generally approximately 50%, of the medicines that are prescribed. This points to our need to improve compliance with medications already available in addition to ordering more appropriate medications.
Example 3 is a chart review form that was developed specifically for our Surgical Service. We have designated some specific surgeries to be reviewed. You may want to modify this based on the surgical procedures that you are interested in. This form serves as an example of modifying the audit to meet specific areas or needs.
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 management as a quality of care outcome. Journal of Nursing Quality Assurance, 1991; 5(2):50- 58.

Betty Ferrell, Margo McCaffery, and Rebecca Ropchan. Pain Management as a Clinical 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 Old Orchard 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 patient interviews is a very important component of quality assurance to improve pain management. We look forward to hearing about your efforts.
Sincerely,
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Betty R. Ferrell, RN, PhD, FAAN Research Scientist
Nursing Research and Education
2/98

CHART AUDIT

Subject #
Medical Record #
Interviewer Initials
Date
1. Patient Setting/Unit
2. Patient Diagnosis
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3. Disease Status:   Cancer/Active Treatment
    Cancer/Remission
    Cancer/Palliative Care
    Other than cancer
4. Current Treatments
         Radiation      Chemo      Surgery       Other (List)
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5. Reason for Admission/Visit
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6. Admitting Medical Service
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Chart Review
7. What is currently prescribed for the patient's pain?
Medication
When Started
Dose
Route
Schedule
8. Is there evidence of use of objective ratings (i.e. visual analogues, rating scales, pain tools)?
  No         Yes
(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 description. (Example: "Physicians progress report says "Pain better.")
10. Has a follow-up evaluation been charted for:
Medications: Yes No Other Modalities Yes No
11. Is pain assessment reflected in:
RN Admission/Hx:
Yes
No
RN Notes-Last 24 Hrs Yes No
RN Care Plan:
Yes
No
MD H&P Yes No
Last MD Progress Note: Yes No
Other: Yes No
PATIENT PAIN INTERVIEW
Your 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. Your answers 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)
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Please answer the following questions by circling the one number on each line that best describes your pain or other symptoms.
7. How much pain do you have right now?
0 1 2 3 4 5 6 7 8 9 10
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 Imagine
10. Do you have a problem with constipation?
0 1 2 3 4 5 6 7 8 9 10
No Pain                          Pain As Bad As You Can Imagine
11. Do you have nausea?
0 1 2 3 4 5 6 7 8 9 10
No Pain                          Pain as Bad as You Can Imagine
12. Do you have a problem with drowsiness or sleepiness from your medication?
0 1 2 3 4 5 6 7 8 9 10
Never                        All the Time
13. 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 At All Satisfied                     Very Satisfied
14. What medicines are you taking for pain? Please list.
Name of Medicine
How Much Is Ordered
How Much Have You Taken In Last 24 Hours
15. 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)
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16. Are you seeing any specialists for help with your pain? (Check any that apply.)
    Anesthesia      Physical Therapy      Pain Team
    Neurology    Psychologist      Occupational Therapy
    Radiation    Other (Describe)
17. Are you using anything other than medicines for your pain?
    Cold    Massage
    Heat    Relaxation
    Imagery    TENS Unit
    Other (Describe)
Please write any other information you would like to share on the back of this survey. Thank you for your help.
Medical Record # Pt. Completed Area Interviewed

CITY OF HOPE NATIONAL MEDICAL CENTER

Chart Review
METHODS: Nursing staff to complete on day of discharge.
1. Patient setting:
2. Patient diagnosis
  • Primary surgical:
  • Primary medical:
  • Other medical:
3. Cause of pain:
4. Surgical procedures
Abdominal:
  •  Gastric, subtotal w/ bypass
  •  Gastric, total w/ bypass
  •  Gastric, other specify
  •  Colon, hemicolectomy w/ colostomy
  •  Colon, hemicolectomy w/ primary anastomosis
  •  Colon, other, specify
  •  Rectal, abdominal- perineal resection, w/ colostomy
  •  Rectal, abdominal- perineal w/low anastamosis
  •  Rectal, other, specify
  •  Pancreatic, whipple procedure
  •  Pancreatic, biopsy w/ bypass
  •  Pancreatic, other, specify
Breast
  •  Mastectomy
  •  Lumpectomy
  •  Axillary node dissection
Chart Review Medical Record #
Page 2 Pt. Completed Area Interviewed
Gynecologic:
  •  Ovarian, TAH/BSO
  •  Corpus uteri, TAH/BSO
  •  Cervix uteri, TAH/BSO
  •  Vulva, Radical vulvectomy
  •  Pelvic exenteration
  •  Other
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Disease Status :
  •  Active treatment
  •  Remission
  •  Palliative
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5. Date of surgery:
6. Date of first ambulation:
7. Complications:  Pneumonia
 Wound infection
8. Prior substance abuse history:  Alcohol                   (taken from H&P)  Narcotics
 Other
9. Is there evidence of use of objective ratings (i.e. visual analogues, rating scales, pain tools)?
 No  Yes Rater                                                    , rating
10. Are there documented descriptions of pain other than objective ratings for the previous 24-hour period?
 No  Yes Rater
Description
DOCUMENTATION:
11. Has a follow-up evaluation been charted for: Medications:  Yes  No
Other modalities:  Yes  No
Chart Review Medical Record #                                   
Page 3 Pt. Completed                Area                
Interviewed    
12. Is pain assessment reflected in:
RN Admission/HX:  Yes  No RN Notes-Last 24 hrs  Yes  No RN Care plan:  Yes  No MD H&P  Yes  No Last MD progress  Yes  No Other:  Yes  No
13. Perioperative pain medications:
Location
Date
Medication
Dose
Route
Taken
Schedule
Pre-Op
OR
Recovery
ICU
Ward
Discharge Meds
Home Phone Follow-Up