Will Introduction of a Pain Assessment Template in an Electronic Medical Record Result in Improvement of Pain Assessment Documentation in an Outpatient Setting

Sunday, 27 July 2014: 3:15 PM

Theresa Ann Pechaty, DNP
Internal Medicine, Ft. Belvoir Community Hospital, Ft. Belvoir, VA


Purpose: This pilot project evaluated whether the pain assessment instrument Brief Pain Inventory (BPI) embedded in the Electronic Medical Record (EMR) used by providers in a primary care setting of Fort Belvoir Community Hospital would improve documentation of pain assessments.

Background/significance:  The Office of the Surgeon General’s Pain Management Task Force (PMTF) determined that pain management in the military treatment system should have a biopsychosocial focus and pain assessments reflect a multidisciplinary approach.  Health-information technology, such as electronic health records, has the potential to facilitate the assessment of pain through the incorporation of valid pain assessment tools that would provide a comprehensive and timely assessment of pain patients.

Methods:  This project used a quasi-experimental design using non equivalent groups to determine the difference, if any, in pain assessment documentation after the introduction of a pain assessment documentation tool, the Brief Pain Inventory (BPI), as a template embedded into the existing EMR.

Results:  The data was aggregated and summarized and a paired t-test was used to compare results between patient encounters pre- and post-implementation of the BPI.  Strong evidence demonstrated a high effectiveness of the BPI to improve pain assessment documentation, particularly in the area of patient functioning:  general activity, walking, work, mood, enjoyment of life, relations with others, and sleep.

Conclusion:   Embedding a validated tool for comprehensive pain assessment in an EMR enables providers to perform a comprehensive assessment of pain patients that reflects a multidisciplinary approach to pain management.