Additional Documentation via Med Verify

We would like to be able to document pain level and descriptors such as cramping, sharp, dull, heavy, etc. It would be nice to be able to put the location of the pain as well. Currently those descriptors are charted in the flowchart, but if it was all in the medication administration screen, it would be allow for more consistent documentation of these items.

Just to give you an example for our small surgical facility - pain management is audited by our quality dept on every patient that stays overnight. They review pain scale, pain location, pattern (ex: acute, chronic, etc), intensity, and the intervention. This is time consuming becasuse if a pain medication is given the nurse is documenting in the flowchart. The reassessment is also in the flowchart. The medication review is in the MAR. - you have to go back and forth to check documentation against the MAR.

Best case scenario would be for this documentation to be captured in the MAR during administration and then reassessment documented in the MAR in the recommended time frame. That way the reviewer would only have to look at the Medication Report or the Patient Progrees Notes. But there is not enough room to enter all the needed documentation. We do not use the reassessment because there is too much duplicate documentation.

Absolute dream would be if the MAR assessment and reassessment documentation would show up in the flowchart also.

You can use the nursing care plan to document intervetions and attach them to the pain questions - but usually the nurse forgets to ONLY document the pain questions and then click the red 'Problem mode' - it's just not intuitive. Then you have the entire assessment to review for the pain intervention in the Problem List report - again - it is not pulling the medication adminsitration either.

Hi Jeanette,
Can you expand on this? What other options/descriptors would you expect to see on the Administration screen? Where are you currently documenting this information?