When it comes to nursing transcription, frequent documentation of pain scores is very important for proper pain assessment and treatment. However, the study findings presented at the American Medical Informatics Associationâ€™s 2014 annual symposium highlight a significant delay on the part of nurses in documenting bedside pain scores. Pain score generally indicates the intensity of pain level. If scores ranging from 1 to 4 indicate a mild level of pain intensity, scores of 5 and 6 indicate moderate level while scores of 7 or higher are reflective (referred pain). Nurses and physicians can make timely interventions based on these scores. Delay in reporting pain scores will prevent them from making timely intervention and this may affect the quality of care.
According to the report published in the Anesthesiology News, the researchers conducted an online survey of 5,876 nurses and observed 25 nurses in inpatient units as a part of this study. On the 1,769 responses received, they found significant lag times between the nursesâ€™ assessing the patient score at the bedside and entering the same into the patientsâ€™ electronic health records (EHRs). It was found that the mean lag time ranged from 16 to 33 minutes. However, longer lag times were found for larger hospitals and patients with lower pain scores. The mean lag time for patients with severe pain scores was found to be 17 minutes compared to 48 minutes for no-pain scores.
According to investigators, the most common reasons quoted for this delay include being too busy with work, having conversations with the patients or their family members, group documentation of pain scores with several patients (for making better use of time) and forgetting to enter the score. During the survey, the nurses suggested that having lighter workloads, using EHR alerts and keeping mobile devices in units can reduce the delay. However, the lead investigator opines the responses indicate the incapability of EHR system as well. It is required to either redesign the system or implement a new system to expedite pain score documentation.
When facing huge workloads, nurses can consider obtaining transcription services to perform EHR transcription and ensure comprehensive, timely and quality documentation. In this approach, the dictations are transcribed by skilled and experienced transcriptionists and the transcribed data is populated into relevant EMR fields so that the documentation is streamlined and accurately maintained. Many professional transcription outsourcing companies provide customized turnaround time so that any delay in documentation can be avoided.