Dream Factory by TruBridge Ideas Portal
When nurses are documenting a medication assessment in response to a dose given, it would be beneficial to have option to enter "Pain Scale ___/10" under that dropdown to simply fill in the blank, rather than having to use the OTHER option to type it out.
This topic as come up again at our facility. We would really need the ability to add the Body location of the pain as well as the 'Pain Scale __/10' option as described.
Just had our survey and we were cited due to no pain assessment prior to administration. Would be very helpful to have this as a part of the administration prompt so that information would be captured and documented.
If we could have a screen like the PCA assessment portion in the mar for other medications that would be incredible!! That way we could chart pain assessment and reassessment with more detail on the MAR
This is a great idea in addition to having the Pain Scale ___/10 there should be a blank for the location and/or intensity of the pain. It could be a list of body locations or a free text blank.
More details and options are definitely needed on the assessment screen. The documentation on the assessment was not sufficient for our state survey because of the character limit and number of options. Staff documents assessment against the med and the assessment comments were adjust to direct them back to the flow chart for detail so that there is adequate documentation of the assessment.
If all medications had an option to attach a specific type of assessment category that may be user defined. Example: pain medication - select assessment and the option would be related to pain such as 0-10 scale, location, intensity if applicable. But if it is a neb treatment the options would be Resp, HR, O2sat, tolerates well, etc. It would save double documentation being done in the flowchart and save extra step for nursing.
It would be nice to have the POSS score added to this also
And carry over to the flowchart so that double documentation isn't necessary. It would be nice to address the Problem list (nursing care plan) at the same time also.