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Pain medication documentation improves substantially

Opportunities remain for post-intervention documentation.


You may have noticed some changes in Epic’s medication administration record (MAR) when administering an opioid medication. On March 14, Epic began recommending documentation of the last pain scaled used and the Pasero Opioid-induced Sedation Scale, or POSS.*

This applies to all areas except the ED and will turn into a hard-stop requirement in the near future.


Monthly internal audits have been tracking compliance with documentation requirements as outlined in Standards for Pain Management policy, including POSS and pain assessment documented prior to opioid dose.

In a short amount of time, the results of the Epic changes are undeniable. System POSS documented prior to opioid dose rose from 42% in February to 84% in March, and system pain assessment documented before opioid dose went from 64% to 88% in the same period.

However, our work to improve patient care and safety around pain management is not complete. Opportunities remain across the system with post-administration documentation.

To ensure intervention efficacy and look for potential side effects, both the POSS and post-pain/comfort intervention reassessment must be completed and documented within one hour after administration. Currently the system average for these essential elements is 66%. Ongoing reassessment of interventions and therapeutic communication are the keys to success and excellent patient care.

Additional information and resources can be found on Asante’s Pain Management website, including policies, fast facts, assessment tools, patient education and communication tools, literature, prescribing information, and staff educational materials.

* If no pain scale was used during the stay, Epic will default to the functional pain scale.

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