Date of Award

6-2016

Document Type

Open Access

Degree Name

Bachelor of Science

Department

Psychology

First Advisor

Carol Weisse

Language

English

Keywords

patients, nurses, visits, clinical, recorded

Abstract

With the growing population of chronically ill patients wishing to receive care at home, care providers face unique challenges managing the pain of patients with quickly changing illness trajectories. Treating patients outside of institutionalized settings, where regular monitoring is standard, requires careful symptom management. This project was a retrospective review examining nurses’ documentation of pain for patients enrolled in Care Choices, a new home-based palliative care program coordinated through a visiting nurse service and community hospital. The extent to which nurses documented patients' pain score, site, type and pain goal as well as nursing interventions and plan of care in Allscripts electronic medical record (EMR) was assessed over a 3-month period. Records from a total of 204 home visits were analyzed for 15 chronically ill patients. The results revealed inconsistent tracking of pain and variations by pain metric. Variable recording practices in the EMR made it difficult to determine whether pain crises were being managed within a desired time period. Aspects of the EMR with the ability to trend quantitative clinical data and chart patient pain goals were also underutilized. Ways of improving the tracking of pain management decisions in chronically ill populations are discussed.

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