EMSC CQI Monitoring Tool

Pediatric Pain Assessment

Confidential, for Quality Improvement Only

Case / # / Patient ID
Optional (for internal use only) / Nurse ID
Optional (for internal use only) / Age
0-15 / Numeric pain scale
assessment on admission (i.e., Wong-Baker Faces, FLACC, 0-10)
Yes No / Interventions:
Medication
or comfort measures
Yes No NA / Reassessment on discharge:
numeric pain scale
Yes No
/ Was pain reduced after intervention?
Yes No NC NA
Ear Pain (Otitis Media) / 1
2
3
4
5
6
7
8
9
10
Laceration / 1
2
3
4
5
6
7
8
9
10
Extremity Fractures / 1
2
3
4
5
6
7
8
9
10
Totals

Population to be reviewed:

·  There will be 10 records of children presenting to the ED ages 0 - 15 years with each of the following diagnoses monitored:

o  Laceration

o  Ear pain (Otitis Media)

o  Extremity fracture

Assessment:

·  All children with the diagnosis of laceration, ear pain (Otitis Media), or extremity fracture will have an initial pain assessment documented using a numeric scale (examples include, but are not limited to: 0 – 10, FLACC, Wong-Baker Faces, etc).

Interventions:

·  All children with a diagnosis of laceration, ear pain (Otitis Media), or extremity fracture will have an intervention(s) documented.

o  Pharmacologic and/or non-pharmacologic interventions are acceptable

o  Narrative description of intervention, documentation of “comfort measures”, or use of check boxes/flowsheet format will be acceptable

o  “N/A” may be entered if the initial pain assessment score = 0.

Reassessment:

·  All children with a diagnosis of laceration, ear pain (Otitis Media), or extremity fracture will have a pain reassessment documented using a numeric scale (examples include, but are not limited to: 0 – 10, FLACC, Wong-Baker Faces, etc)

upon discharge from the ED.

Pain Reduction after Intervention:

·  If answer is “Yes” to both assessment and reassessment documentation, record if the pain was reduced

o  “No change” (NC) may be entered if pain intensity was documented as exactly the same as initial assessment

o  “N/A” may be entered if either the assessment or reassessment was not documented