Evaluation of pain management documentation

Objectives: Accurate and consistent documentation of pain management, including patient responses regarding improvement in pain scores, is essential for improving patient care. The objective of the project was to evaluate the current prescribing patterns and to review the current documentation for opioid-managed, chronic pain patients in an academic continuity of care medicine clinic. Methods: Retrospective data were extracted from currently managed adult, opioid patients to evaluate prescribing patterns and to review documentation processes. Results: Results reveal inconsistent to absent documentation with most patients receiving prescriptions from multiple providers. Oxycodone/acetaminophen was the most frequently prescribed analgesic. Conclusion: The results of this evaluation highlight the opportunity for educational intervention and the development of a structured, institution-specific guideline for prescribing and documenting pain management.