Understanding and Documenting Pain in Clinical Practice: A Call for Improvements

Abstract

Pain remains the most common complaint among patients in all healthcare settings, yet its assessment and documentation continue to present challenges. In Ireland, an estimated 1.2% of GDP is spent annually on pain management though the true burden of pain on total healthcare resources is still unclear. To date, little is known of the prevalence of staff understanding of pain and the distribution of general in-patient pain management practices in Ireland.

The National Rehabilitation Hospital (NRH) in Dublin undertook parallel studies to investigate staff understanding of pain and the adequacy of pain documentation within the Trakcare electronic health record (EHR). 133 clinical staff across all disciplines were surveyed over 16 days, representing approximately 30% of all clinical NRH staff. Data from the first seven months of EHR data, representing 2114 positive pain assessments, was extracted, anonymised and triaged by staff role to minimise bias prior to analysis. Responses were scored for completeness and clinical utility, and analysed for adherence to standardised methodologies.