Audit Name:Pain Interfering with Activity in Acute Orthopedic Conditions

Reason for Audit:OASIS/ORYX Action Team Monitoring

Sample Criteria:Patients with ACUTE orthopedic condition as PRIMARY diagnosis

( in the NA box denotes Yes or No is the only acceptable answer.)

DEMOGRAPHICS: (Minimum data—must compete all * fields)

*Client Name: / *SOC Date: / *Area:
*Acct #: / *MR# / *Primary HV Staff:
*Time Period Reviewed: / *Other disciplines:
*Reviewer: / *Review Date:
Audit Questions / Yes / No / NA
1.CHN/Therapist assess severity of pain on OPENING visit using 0-10 scale?
  • If patient does not have pain on opening do not continue audit. Choose another patient.

2.CHN/Therapist assess severity of pain on EVERY SUBSEQUENT visit using 0-10 scale? (If severity on opening is  5 per system standards)
3.CHN/Therapist establish acceptable pain rating with patient? (May be at opening visit or when pain is a problem.)
4.If pharmacological measures for pain relief are ineffective, CHN consults with MD within same calendar day as the visit? (Severe pain rating of 8-10 requires intervention.)
5.CHN/PT assess patient knowledge of pharmacological measures to reduce pain (i.e. rationale, dose, route, frequency, side effects)?
6.CHN instructs patient on pharmacological measures to reduce pain? (Treatment/communication with the same persistence and resolution as other vital signs falling out of normal parameters.)
7.CHN/PT assess patient knowledge of non-pharmacological measures to reduce pain (i.e. change in position, relaxation techniques, and visualization)?
8.CHN/PT instructs patient on non-pharmacological measures to reduce pain?
Audit Questions / Yes / No / NA
9.Does this patient have acute pain?
10.Does this patient have mixed pain (chronic and acute)? Presence of chronic pain 8 triggers a more detailed pain assessment, which includes but is not limited to?
  1. Location(s)
  2. Intensity (0-10 scale)
  3. Quality (e.g. stabbing, gnawing, aching, burning,)
  4. Acceptable pain level for the patient
  5. Medications or interventions used for pain relief and effectiveness
  6. How pain affects function (i.e. activity, sleep) and quality of life
(Reference: all per VPI Pain Assessment Guidelines found in Pain Resource Manual.)
Chronic pain is defined as any pain which lasts longer than normally expected for that specific type of acute pain; it often is without tissue damage (reference: Pain Management Protocol VPI found in Pain Resource Manual.)

CONFIDENTIAL QUALITY REVIEW DATA

For Performance Improvement Use Only