AFFILIATE ORIENTATION MANUAL The purpose of the policy is to provide optimum pain management to all patients in a safe and effective manner for pain perceived and reported by the patient and/or assessed by the caregiver. Policy All patients have a right to appropriate assessment and management of pain. This assessment will be age-appropriate, culturally appropriate, and facilitate regular reassessment and follow up. Cone Health will plan, support, and coordinate activities and resources to assure that each patient’s pain is recognized and addressed appropriately. Procedure Establish and maintain competency in pain management for appropriate clinical staff. In all inpatient settings, pain will be routinely assessed, reassessed, and documented at least once during a shift or with a report of new or different pain. In the outpatient setting, pain will be assessed during the visit as appropriate to the treatment, diagnosis or chief complaint. In the initial/admission assessment, the goal is to identify and document the presence or absence of pain. If pain is present, complete a more comprehensive assessment, which may include: • Location. • Pain intensity (using approved scale). • Quality; patterns of radiation, if any; and character (elicit and record the patient’s own words whenever possible). • Onset, duration, variation and patterns. • Alleviating and aggravating factors. • Effects of pain (impact on daily life, function, sleep, appetite, relationships with others, etc.). • Pain goal. Reassessment of pain: Pain reassessment, post- intervention, will occur within a reasonable time frame based on the actions of the medication and the route of administration. Document ongoing assessments and follow up to interventions according to patient condition. Accept and treat findings of pain assessment. Document all interventions. Instruct the patient and family members regarding: • Rights to pain management. • Understanding pain management. • Risks for unrelieved pain. • How to report pain and relief. • Pharmacological and non-pharmacological methods of treatment. Address patient’s pain management needs in the discharge plan or end-of-visit summary. PAIN MANAGEMENT and ASSESSMENT POLICY 27