A chart audit of postoperative pain assessment and documentation: the first step to implement pain assessment as the fifth vital sign in a University Hospital in Thailand.

ABSTRACT

PURPOSE: To describe the documentation of pain assessment and management in the first 72 hrs postoperatively. DESIGNS Retrospective descriptive study MATERIAL AND METHOD: Four hundred and twenty five hospital charts in December 2002 were audited to reveal the quality of postoperative pain assessment and documentation. Scores above 21 from the possible maximum of 28 (75%) were accepted for the review. RESULTS: Nurses documented pain assessment more often than doctors (98.8% vs 29.4%). An assessment of pain intensity using a numerical rating scale (0 to 10) was found in 192 (45.2%) charts, and using a pain descriptor scale in 408 (96%) charts. The documentation of pain both before and after giving analgesics was scarce during the first 3 days postoperatively. Apart from charts that used a patient-controlled analgesia (PCA) technique which had a specific record form, regular pain assessment every 2 to 4 hrs during the first 24 hrs was found in only 2 (0.5%) charts. Pain assessment items which were documented inconsistently and below accepted standards were pain assessment after administration of analgesics, pain assessment every 2 hours in the first 24 hours (day 1), and pain assessment thereafter every 4 hours in the first 24-72 hours (days 2 and 3). The other 4 of 7 audit pain items were documented in higher scores initial patients' pain intensity and sedation assessment, pain treatment, continuity of pain assessment and pain assessor s name scores. Nevertheless, because of the low total audit score [mean+/-SD = 10.7+/-3 out of 28], it was considered that none of the reviewed charts reflected good quality pain assessment and documentation. CONCLUSION: The present study revealed that the existing practices of pain assessment and documentation were poor. The need for development of regular pain assessment as if pain is the fifth vital sign should be widely emphasized as a part of quality assurance.