Process audit of pain assessment recording in hospitalised canine ophthalmology patients.

Aims and objectives: The aim of this process audit was to assess if pain assessment in hospitalised canine ophthalmology patients was being documented and if found to be undocumented, implementing changes to improve this.

Background

Pain scoring anecdotally appeared to be recorded less in ophthalmology patients than in other patients in the practice. This was of particular concern to veterinary staff working out of hours shifts who rely on hospital records to monitor changes in patient condition. The target was for all patients to have a pain assessment recorded.

Methods

The records of 30 patients were analysed to find out how many had a pain score chart completed when requested or if they had any notes regarding pain assessment recorded on their hospital sheet.

Results

The initial audit data collected confirmed the suspicion that pain scoring was not adequately recorded in hospitalised canine ophthalmology patients, with 57% of patients having no pain assessment recorded. Implementation of changes (team discussion & changes made) and re-audit: One month after implementing interventions that required staff to record signs of ocular pain on the patients hospital sheet, and the development of a mnemonic to remind staff of these signs and as the placement of reminder signs in prominent areas, a re-audit was performed. This showed significant improvement; 96% of patients had a pain assessment recorded. Application: Performing this clinical audit enabled the practice to identify an area where improvements needed to be made. The team collaborated to devise a set of interventions they felt would address this issue improved the recording of pain assessment in this practice. This has allowed staff on differing shifts to recognise changes promptly and ultimately improve the wellbeing of patients. Other practices may find the interventions useful and wish to perform a similar audit.