Date of Graduation

Spring 5-19-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


On a 28 bed post-surgical unit, reviewing patient records revealed only 26% had thorough patient controlled analgesia (PCA) documentation. A pre-quiz no staff knew all of the required components for documentation or which policies to reference and, on average, the staff were only able to correctly answer 30% of the questions. Therefore, a project utilizing the clinical nurse leader improvement theme of clinical outcomes management was initiated to standardize the documentation of PCA medication administration to improve post-operative pain management, improve patient satisfaction, and improve patient safety.

The current process was determined using a fishbone diagram, a SWOT analysis was conducted to maximize the strengths and opportunities and minimize the weaknesses and threats, in-services were provided, and individual feedback was given as needed. Copies of policy TX-35: Pain Management, the Pain Reassessment policy, the PowerPoint, and quick reference guides on clearing the shift totals and retrieving cleared data were provided to staff.

After the in-services, the nursing staff answered 84% of the quiz questions correctly and chart reviews revealed a documentation compliance of 60%. These results demonstrated an increased awareness of facility policy. Furthermore, 100% of the staff stated they were clear on the requirements of pain documentation.