Author Biographical Info

DOCTOR OF NURSING PRACTICE

Date of Doctor of Nursing Practice Project Completion

2026

Faculty Advisor

Robert Carl Coghlan III PhD, RN, MSN, MA, CNS, FNP

Abstract

Improving Nursing Compliance with Pain Reassessment Documentation After Analgesic Administration

PURPOSE: This quality improvement project aimed to increase registered nurse (RN) compliance with documenting pain reassessment within 30–60 minutes after analgesic administration in an adult medical–surgical trauma unit at a large academic medical center.

BACKGROUND: Timely pain reassessment is essential for evaluating treatment effectiveness and ensuring safe, patient-centered care. Baseline audits showed inconsistent documentation and compliance below institutional expectations. Evidence supports the use of electronic health record (EHR) prompts combined with targeted nursing education to improve adherence.

METHODOLOGY: A 12-week quality improvement initiative was conducted to reinforce adherence to the existing pain reassessment protocol. The intervention emphasized consistent use of the existing Epic Best Practice Alert (BPA), supported by brief targeted nursing education and ongoing reinforcement strategies. Compliance data were collected through EHR chart audits and analyzed using run charts to assess trends. One Plan-Do-Study-Act (PDSA) cycle experienced a brief delay due to a project site change and additional institutional requirements.

RESULTS: Pain reassessment documentation compliance improved from 65% pre-intervention to 86% post-intervention. Mid-project monitoring showed a temporary peak compliance of 92%. Units with higher participation in educational sessions demonstrated greater adherence.

IMPLICATIONS: Integrating EHR reminders with targeted education improves adherence to pain reassessment documentation. Findings support system-based prompts and ongoing staff education to enhance documentation practices and sustain quality improvement. This project highlights the impact of nurse-led initiatives in strengthening accountability and improving patient care outcomes.


Keywords

: pain reassessment, nursing documentation, quality improvement, EHR alerts, analgesic administration

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