Ambulatory Care Setting Pain Screening and Assessment Documentation

Completion of pain screening and assessment for all patients supports the Joint Commission standard to have a process in place to evaluate, treat and/or refer patients for pain treatment. Currently, our hospital-based institutional policies for outpatient clinics require a pain screen to be completed during patient office visit evaluations. Additionally, a pain assessment should be conducted for any positive response to a pain screen.

Currently, medical office assistants (MOAs) are not allowed to conduct clinical assessments. The existing pain screen included assessment questions and there was no clear delineation between screening and assessment. This allowed the MOA to conduct an assessment of pain which is not compliant with their scope of service. By redesigning and implementing a new pain documentation tool, we planned to decrease MOA completion of pain assessment components in the physical medicine and rehabilitation (PM&R) clinic from 100% baseline to 5% post-implementation (November through December 2023).

Through reviewing current workflow practices and policies and by conducting research/brainstorming sessions on our electronic medical record (EMR) functionality, our informatics team, with the assistance of the EMR team, was able to develop a new pain assessment tool. Once the tool was tested and presented to several clinical practice committees and policy/operations teams, the tool was implemented across all clinics at the organization. Additional resources were provided for clinic leadership, such as a tip sheet for the new workflow and a documentation compliance report that the clinic manager could run ad hoc. With the new pain documentation tool available to clinic staff, we began gathering data to review the efficacy of the tool in the PM&R clinic.

Overall, the creation of a new pain assessment tool has eliminated the occurrences of MOAs inappropriately completing pain assessment questions. However, there was a reduction in the number of pain screens that were being completed for office visits across the organization. Therefore, an additional gap analysis can be used to investigate the reduction of pain screens for office visits.

In conclusion, nurses now have access to a tool that allows them to collect valuable pain evaluation data in a standardized format that is easily accessible within the EMR and the MOAs are no longer inadvertently stepping outside of their scope of service.