Action Plan: Auditing Nurse Supervisor provides education to staff during auditing process. Nursing administration will continue to follow up and audit all falls. Pain Assessment Carolyn Dimek, RN, MS Pain Re-Assessment Audit Form I. Measure Name: Pain Reassessment Audit - Patient Recovery Measure Description: Untreated pain impairs an individual’s ability to carry out their activities of daily living diminishing his or her quality of life; it can cause anxiety, fear, anger, or depression. Nursing acknowledges the impact of untreated pain on patient recovery and for this reason the objective of Nursing’s Pain PI is to ensure patients are being assessed for pain and re-assessed if required. All MARs are reviewed for the month for pain reported and corresponding reassessment; the information is located on form #838 ‘Pain Flow Sheet.’ The information is documented on the “Pain Assessment and Re-assessment Audit Form” for monthly and quarterly calculation. Audits were initiated in January 2013, January and February 2013 comprise the baseline data of 38%. Type of Measure: Performance Improvement Results Baseline 1Q 2Q 3Q 4Q Jan/Feb Target Data elements YTD 2017 2017 2017 2017 2013 Number of audits performed 89 116 87 118 41 362 Number of patients with 29 65 51 53 17 186 pain reported on Form 838 Number of reassessments 11 47 40 52 16 155 completed Number of reassessments reported within clinically 90% appropriate timeframe Compliance 11 47 40 52 16 155 (1-2 hours after oral medication and within 1 hour of intramuscular
Action Plan: Auditing Nurse Supervisor provides education to staff during auditing process. Nursing administration will continue to follow up and audit all falls. Pain Assessment Carolyn Dimek, RN, MS Pain Re-Assessment Audit Form I. Measure Name: Pain Reassessment Audit - Patient Recovery Measure Description: Untreated pain impairs an individual’s ability to carry out their activities of daily living diminishing his or her quality of life; it can cause anxiety, fear, anger, or depression. Nursing acknowledges the impact of untreated pain on patient recovery and for this reason the objective of Nursing’s Pain PI is to ensure patients are being assessed for pain and re-assessed if required. All MARs are reviewed for the month for pain reported and corresponding reassessment; the information is located on form #838 ‘Pain Flow Sheet.’ The information is documented on the “Pain Assessment and Re-assessment Audit Form” for monthly and quarterly calculation. Audits were initiated in January 2013, January and February 2013 comprise the baseline data of 38%. Type of Measure: Performance Improvement Results Target Data elements Baseline Jan/Feb 2013 1Q 2017 2Q 2017 3Q 2017 4Q 2017 YTD 90% Compliance Number of audits performed 89 116 87 118 41 362 Number of patients with pain reported on Form 838 29 65 51 53 17 186 Number of reassessments completed 11 47 40 52 16 155 Number of reassessments reported within clinically appropriate timeframe (1-2 hours after oral medication and within 1 hour of intramuscular 11 47 40 52 16 155
4Q2017.docx