General database questions.

Questions about drugs/procedures not included on the medical record audit form.

Questions about the data-entry form.

Questions about the Medical Record Audit Summary report.

Questions about the Quality Indicator Report Card report.

1. Review nursing flowsheets, physician orders, medication record sheets, history & clinical notes (and critical path or care plan, if appropriate) for the first 24 hours after return to nursing unit after surgery (as long as it is within 72 hours after surgery).  Do not include post-anesthesia room (pacu) orders or treatment.

2. If medical patient, audit first 24 hours after admission.

ID Number

Code number ______                                 Age ______

Admit or Surgical Date ___/___/___           Unit ___/__

Ethnicity: ___ Caucasian                              Sex:  ____  M  ____ F
              ___ Hispanic 
              ___ African-American
              ___ Asian
              ___ American Indian
              ___ Other

Diagnosis: ___ Medical Cancer  ___ Medical Non-Cancer ___ Surgical Cancer  ___ Surgical Non-Cancer

Diagnosis description: 

ASSESSMENT

Was there any documentation of pain by a physician?                              ___ Yes ___ No

In the charts where a physician documented pain, did the physician’s 
documentation include the use of either a numeric (e.g. 0-10, 0-5) or 
descriptive (e.g. mild-moderate-severe) pain intensity scale?                    ___ Yes ___ No

Was there documentation of pain by a nurse?                                          ___ Yes ___ No

In the charts where a nurse documented pain, did the nurses’ 
documentation include the use of either a numeric (e.g. 0-10. 0-5) or 
descriptive (e.g. mild-moderate-severe) pain intensity scale?                    ___ Yes ___ No

How many pain intensity ratings (either numeric or descriptive) 
were recorded during this 24 hour period by the RNs?
 

OUTCOME

Of all documented pain ratings, how many were either > 5 (scale 0-10) or > 3 (scale 0-5) or moderate or severe?

What was the highest pain rating recorded? 

What was the lowest pain rating recorded? 
 

TREATMENT

Is there any documentation that non-pharmacologic interventions were used to treat pain? ___ Yes ___ No

If yes, indicate all that were documented:                                   ___ Heat  ___ Cold

                                                                                                ___ Relaxation  ___ Massage

                                                                                                 ___ Imagery  ___ Distraction

                                                                                                 ___ Music  ___ Positioning or Movement 

                                                                                                 ___ Patient Teaching ___ Splinting

                                                                                                 ___ TENS  ___ Other (specify)

Were IM (intramuscular injections) ordered as a route for any opioid analgesics?        ___ Yes ___ No
If yes,  ___ PRN ___ Scheduled
How many times was an IM opioid analgesic administered?  ______
Total mg of opioid analgesic administered IM    ______ mg
IM opioid administered:  ___ Morphine  ___ Dilaudid ___ Demerol  ___ Other (specify) _____________

Was ketorolac (Toradol) ordered? ___ Yes ___ No
If yes, ___ PRN ___ Scheduled
How many times was an (IM/IV) injection of ketorolac (Toradol) administered? ______
Total mg amount of ketorolac administered?      ______ mg
 

Was meperidine (Demerol) ordered?      ___ Yes ___ No
If yes, ___ PRN ___ Scheduled
How many times was a dose of meperidine administered?   ______
Total mg amount of meperidine administered    ______ mg

Did this patient receive analgesics via an intravenous patient-controlled analgesic pump (IV PCA)?     ___ Yes ___ No
If yes, did patient receive the basal rate?   ___ Yes ___ Noc only ___ No
Pt initiated dose (mg) _____ mg
Basal rate (mg)  _____ mg
Lockout (minutes) _____
PRN RN IV bolus (mg)  _____ mg 
Total amount of opioid received from IV PCA _____ mg
IV opioid administered: ___ Morphine  ___ Dilaudid ___ Demerol  ___ Fentanyl  ___ Unable to determine

(Excluding IV PCA) Were intravenous (IV) injections of an opioid analgesic ordered?       ___ Yes ___ No
If yes, ___ PRN ___ Scheduled
How many times was an IV injection of an opioid administered?  ______
Total mg amount of IV opioid administered?     ______ mg
IV opioid administered: ___ Morphine  ___ Dilaudid  ___ Demerol  ___ Other (specify)

Did this patient receive analgesics via an epidural catheter (post-op)?     ___ Yes ___ No
       ___ Continuous ___ PCA ___ Bolus

Were oral opioid (include combination products) analgesics ordered? ___ Yes ___ No
If yes,  ___ PRN ___ Scheduled
How many times was an oral opioid administered?    ______
Total mg amount of oral opioid administered     ______ mg
Oral opioid administered:  ___ Codeine  ___ Hydrocodone  ___ Oxycodone  ___ Morphine
Was it a combination product?      ___ Yes ___ No

Were oral opioid (include combination products) analgesics ordered? ___ Yes ___ No
If yes,  ___ PRN ___ Scheduled
How many times was an oral opioid administered?    ______
Total mg amount of oral opioid administered     ______ mg
Oral opioid administered:  ___ Codeine  ___ Hydrocodone ___ Oxycodone  ___ Morphine
Was it a combination product?      ___ Yes ___ No

Were oral non-steroidal anti-inflammatory (NSAIDs) analgesics ordered? ___ Yes ___ No
If yes, ___ PRN ___ Scheduled
How many times was an oral non-opioid given?    ______

(Excluding combination products) Was acetaminophen (Tylenol) ordered?        ___ Yes ___ No
If yes, ___ PRN ___ Scheduled
How many times was acetaminophen administered?   ______
Total mg amount of acetaminophen administered    ______ mg

During this first 24 hours, did the patient receive a change in analgesic orders?        ___ Yes ___ No
If yes, was the analgesic regimen    ____ increased   ____ decreased
If yes, why (check all that apply)?   ___ side effects 
                                                      ___ pain not controlled
                                                      ___ patient’s PO status changed
                                                      ___ unable to determine
                                                      ___ other