Linking nursing pain assessment, decision-making and documentation

Abstract

A clinical nurse specialist's (CNS) experience in the development and implementation of a pain assessment and treatment flowsheet (PATF) to enhance the nursing assessment, decision-making, and documentation of pain on a palliative care unit in a community hospital is described in this article. Members of the palliative care interdisciplinary team use the PATF for clinical decision-making in the day-to-day management of patients' pain. The PATF is undergoing revision and re-implementation to promote the utilization of the tool beyond the specialty of palliative care and into the general patient population.