JCAHO in the year 2000 has developed criteria in the manner in which pain should be assessed and documented. The Nurses need to be competent in evaluating and documenting pain. The patient has to also be reassessed for pain on a routine basis. If pain is affecting normal functioning at any stage, effective measures need to be taken to ensure rehabilitation and relief. The nurse would have to assess pain at various events including admission of the patient, reporting of pain to other healthcare professionals, after procedures or surgeries, or during discharge planning.
Various criteria of pain including location, duration, intensity, frequency, character and comfort levels need to be recorded. A Numeric Pain Rating Scale should be used in the EMR to determine the level of pain from 0 to 10. In patients who are not communicating, the FLACC pain scale should be used. Preferable Pain assessment should be done in the nursing flow sheet (which would help review the pain characteristics at various period of time) (University of Virginia, 2008).
• Medication administration – the Drug being administered should be named appropriately so that any previous drug allergy reaction that the patient experienced can be identified before actually prescribing the drug. The physician prescribing the drug can import the drugs from the online catalog. There are several tools which work on the back-end of the EMR which can effectively help to determine any drug allergy or drug interactions risks. It is important that the physician enter the patient’s age, sex, weight and height, and also any over-the counter drugs.
In some instances, the patient’s EMR including the laboratory results and complications should be updated to ensure that any new problem does not contradict the chances of drug adverse reaction (JAMIA, 2008). • Verbal telephone orders – The requirement strictly says that any person who is supposed to receive a critical test result, verify the same by sending in a read-back message. Usually, the JCAHO does not encourage the use of verbal orders, but in case it is unavoidable, the organization itself needs to thoroughly review the manner in which verbal orders are handled.
The person receiving the order should write down the details and send back as a message, requesting a read-back message (JCAHO, 2005). • Others – JCAHO is strongly committed to address adverse effects of falls especially in elderly individuals. Periodically, the elder’s risk of fall needs to be assessed and documented. A fall prevention program needs to be implemented and documented. Measures should be taken at the hospital and at home to prevent elders from falling. Falls risk assessment and management is an interdisciplinary approach.Elders also need to be adequately counseled about the fall risk (Biz Quest, 2008).
References:
Biz Quest (2008). JCAHO Goal and Requirement re Falls-risk identification, Assessment and Prevention, Retrieved on June 7, 2009, from Web site: http://74. 125. 153. 132/search? q=cache:ZCgyO9xRjoAJ:www. bizquest. com/myaccount/listing/upload_downloadfile. asp%3Ffile_id%3D28468+falls+documentation+JCAHO+requirement&cd=2&hl=en&ct=clnk&gl=in&client=firefox-a JCAHO (2005). Patient Safety, USA: JCAHO Resources.
http://books. google. co. in/books? id=O72xa32NgzYC JAMIA (2008). Recommended Features and Elements needed for an eRx System to Provide Effective, High-Value CDS, Retrieved on June 7, 2009, from Web site: http://www. jamia. org/cgi/content/full/12/4/365/TBL2 University of Virginia Health Systems (2008). Pain Management per JCAHO, Retrieved on June 7, 2009, from Web site: http://www. healthsystem. virginia. edu/internet/pnso/NEW/ProfDev/KnowledgeSharingDocs/Pain-Management-for-staff-4W-6-07. ppt