Date of Graduation

Spring 5-17-2024

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Jennifer Zesati, MSN, RN, CCRN


Problem The fifth vital sign, pain, requires proper pain management in hospital settings, often involving opioids with significant risks of adverse reactions. Appropriate pain assessment and management is vital to ensure safe medication administration and mitigate potential adverse reactions.

Context This quality improvement (QI) project aimed to enhance opioid assessment and documentation rate above 90% compliance in two medical-surgical units, with a focus on bedside nurses. Nurses play a key role in administering and documenting pain assessments, a practice crucial to managing patient safety and effective pain management specific to opioid use.

Intervention A baseline survey provided nurses’ understanding on compliance criteria and assessment timing. Interventions included visual reminders, informational posters, and instructions on how to access individual self-compliance reports.

Measures A post-intervention survey assessed effectiveness and gathered feedback from nurses. April quarterly quality report data will be used to measure compliance rates for pain pre- and post-assessment documentation and compared with pre-intervention February quality report data. Alternatively, manual auditing of the electronic health record (EHR) for both units was performed to obtain preliminary post-intervention compliance data.

Results Post-intervention results from April reports exhibited a decline of 7% in compliance rate for pre-assessment in unit A, but an increase by 0.5% for post-assessment documentation. Conversely, unit B displayed a 6.3% increase in pre-assessment documentation compliance and a 3.5% increase in post-assessment documentation rate.

Conclusion Usage of visual aids to prompt pain assessment and reassessment documentation, coupled with enhanced nurse education on extracting self-compliance reports, have potential for enhancing nurse documentation compliance rates within medical-surgical units.

Keywords: pain assessment, reassessment, documentation, medical-surgical, opioids

Included in

Nursing Commons