Method: The clinical informatics team began the automation of clinical documentation in May 2001. The scope of this project was divided into two phases. Phase I included documentation of admission history and pain assessment. Phase II included shift documentation of physical assessment, interdisciplinary care planning, discharge planning, and interdisciplinary education documentation related to pain. The clinical informatics team created computerized documentation pathways, including the pain assessment process. In conjunction with the family, the caregiver was instructed to select the appropriate scale for pain assessment and management. The caregiver was educated to document the pain score using the computerized screen specific to the pain scale. A Pain Task Force was developed to implement the organization strategies to improve pain management. Prompts, added to the documentation process in July 2003, were instrumental in reminding caregiver's of the need for continued pain assessment. Weekly chart audits were completed to measure compliance with “real time” charting. Computer system reports were generated weekly to measure compliance with timely reassessment following pain intervention.

Results: Preliminary analysis of weekly system reports reveals a 68% increase in reassessment within 60 minutes of the pain intervention over a 24-month period. Audits demonstrate a 22% increase in “real time” charting for pain documentation over an 18-month period following implementation of the computer prompts.

Conclusion/Implications: The effectiveness of the computerized pain documentation along with the electronic prompting of pain assessment shows continuous improvement over a 24-month time frame. These strategies will be expanded in our organization to improve timeliness and quality of other clinical assessments, patient safety, and documentation.