Improving pain reassessment documentation practices among nurses in a central Montana progressive care unit

Abstract

Background: Timely pain reassessment following analgesic administration is essential for patient safety, quality care, and regulatory compliance. Despite this, documentation adherence remains inconsistent in many acute care settings. Purpose: This quality improvement project aimed to increase adherence to timely pain reassessment documentation among nursing staff on a progressive care unit. Methods: A multifaceted intervention was implemented to improve awareness, knowledge, and accountability. Strategies included live education sessions on institutional pain policy, visual reminder aids at workstation computers, and ongoing audit and feedback of monthly documentation rates. Education attendance was tracked, with supplemental written materials provided to non-attendees. Documentation adherence data were obtained through retrospective review of monthly electronic health record (EHR) reports and compared across pre- and post- intervention periods. Results: Baseline adherence was approximately 32% (n=57). Following initial EHR-related changes, adherence increased to 41% (n=56) in November and 53% (n= in December. After full implementation of interventions, adherence improved to 54% (n=v58) in January and 60% (n=61) in February. Education sessions reached 64% of staff, with 100% receiving educational content. Post-implementation feedback indicated 100% of respondents reported increased comfort with documentation, and audit and feedback were identified as the most effective intervention. Conclusions: A multifaceted approach incorporating education, visual reminders, and audit and feedback improved pain reassessment documentation adherence. Ongoing monitoring and reinforcement may support sustained improvement and enhance safe, consistent pain management practices.