On a 28 bed post-surgical unit, reviewing patient records revealed only 26% had thorough patient controlled analgesia (PCA) documentation. A pre-quiz no staff knew all of the required components for documentation or which policies to reference and, on average, the staff were only able to correctly answer 30% of the questions. Therefore, a project utilizing the clinical nurse leader improvement theme of clinical outcomes management was initiated to standardize the documentation of PCA medication administration to improve post-operative pain management, improve patient satisfaction, and improve patient safety.
The current process was determined using a fishbone diagram, a SWOT analysis was conducted to maximize the strengths and opportunities and minimize the weaknesses and threats, in-services were provided, and individual feedback was given as needed. Copies of policy TX-35: Pain Management, the Pain Reassessment policy, the PowerPoint, and quick reference guides on clearing the shift totals and retrieving cleared data were provided to staff.
After the in-services, the nursing staff answered 84% of the quiz questions correctly and chart reviews revealed a documentation compliance of 60%. These results demonstrated an increased awareness of facility policy. Furthermore, 100% of the staff stated they were clear on the requirements of pain documentation.
","abstract_html":"<p>On a 28 bed post-surgical unit, reviewing patient records revealed only 26% had thorough patient controlled analgesia (PCA) documentation. A pre-quiz no staff knew all of the required components for documentation or which policies to reference and, on average, the staff were only able to correctly answer 30% of the questions. Therefore, a project utilizing the clinical nurse leader improvement theme of clinical outcomes management was initiated to standardize the documentation of PCA medication administration to improve post-operative pain management, improve patient satisfaction, and improve patient safety.</p> <p>The current process was determined using a fishbone diagram, a SWOT analysis was conducted to maximize the strengths and opportunities and minimize the weaknesses and threats, in-services were provided, and individual feedback was given as needed. Copies of policy TX-35: Pain Management, the Pain Reassessment policy, the PowerPoint, and quick reference guides on clearing the shift totals and retrieving cleared data were provided to staff. </p> <p>After the in-services, the nursing staff answered 84% of the quiz questions correctly and chart reviews revealed a documentation compliance of 60%. These results demonstrated an increased awareness of facility policy. Furthermore, 100% of the staff stated they were clear on the requirements of pain documentation. </p>","abstract_has_math":false,"creators":["West, Collyn"],"institution":null,"degree_name":"Master of Science in Nursing (MSN)","degree_level":"Project/Capstone - Global access","degree_discipline":null,"degree_department":null,"school":null,"contributors":[],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2016,"date_issued":"2016-05-19T07:00:00Z","date_published":"2016-05-19T07:00:00Z","updated_at":"2026-07-24T05:43:31Z","subjects":["Patient Controlled Analgesia","PCA","Documentation","Perioperative, Operating Room and Surgical Nursing"],"languages":[],"rights":[],"rights_urls":[],"identifier_entries":[]},"links":{"outbound_url":"https://repository.usfca.edu/capstone/278","outbound_label":"Repository record","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:creator","label":"Author","values":["West, Collyn"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date.available","label":"Dc Date Available","values":["2016-04-27T07:00:00Z"]},{"key":"thesis:degree_level","label":"Degree Level","values":["Project/Capstone - Global access"]},{"key":"thesis:degree_name","label":"Degree Name","values":["Master of Science in Nursing (MSN)"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Patient Controlled Analgesia","PCA","Documentation","Perioperative, Operating Room and Surgical Nursing"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://repository.usfca.edu/capstone/278"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description.abstract","label":"Abstract","values":["On a 28 bed post-surgical unit, reviewing patient records revealed only 26% had thorough patient controlled analgesia (PCA) documentation. A pre-quiz no staff knew all of the required components for documentation or which policies to reference and, on average, the staff were only able to correctly answer 30% of the questions. Therefore, a project utilizing the clinical nurse leader improvement theme of clinical outcomes management was initiated to standardize the documentation of PCA medication administration to improve post-operative pain management, improve patient satisfaction, and improve patient safety.
The current process was determined using a fishbone diagram, a SWOT analysis was conducted to maximize the strengths and opportunities and minimize the weaknesses and threats, in-services were provided, and individual feedback was given as needed. Copies of policy TX-35: Pain Management, the Pain Reassessment policy, the PowerPoint, and quick reference guides on clearing the shift totals and retrieving cleared data were provided to staff.
After the in-services, the nursing staff answered 84% of the quiz questions correctly and chart reviews revealed a documentation compliance of 60%. These results demonstrated an increased awareness of facility policy. Furthermore, 100% of the staff stated they were clear on the requirements of pain documentation.
"]},{"key":"dc:title","label":"Title","values":["The Development of Standardized Patient Controlled Analgesia Documentation to Improve Patient Care"]}]}],"canonical_facts":{"dc:creator":["West, Collyn"],"dc:date.available":["2016-04-27T07:00:00Z"],"dc:description.abstract":["On a 28 bed post-surgical unit, reviewing patient records revealed only 26% had thorough patient controlled analgesia (PCA) documentation. A pre-quiz no staff knew all of the required components for documentation or which policies to reference and, on average, the staff were only able to correctly answer 30% of the questions. Therefore, a project utilizing the clinical nurse leader improvement theme of clinical outcomes management was initiated to standardize the documentation of PCA medication administration to improve post-operative pain management, improve patient satisfaction, and improve patient safety.
The current process was determined using a fishbone diagram, a SWOT analysis was conducted to maximize the strengths and opportunities and minimize the weaknesses and threats, in-services were provided, and individual feedback was given as needed. Copies of policy TX-35: Pain Management, the Pain Reassessment policy, the PowerPoint, and quick reference guides on clearing the shift totals and retrieving cleared data were provided to staff.
After the in-services, the nursing staff answered 84% of the quiz questions correctly and chart reviews revealed a documentation compliance of 60%. These results demonstrated an increased awareness of facility policy. Furthermore, 100% of the staff stated they were clear on the requirements of pain documentation.
"],"dc:identifier":["https://repository.usfca.edu/capstone/278"],"dc:subject":["Patient Controlled Analgesia","PCA","Documentation","Perioperative, Operating Room and Surgical Nursing"],"dc:title":["The Development of Standardized Patient Controlled Analgesia Documentation to Improve Patient Care"],"thesis:degree_level":["Project/Capstone - Global access"],"thesis:degree_name":["Master of Science in Nursing (MSN)"]},"updated_at":"2026-07-24T05:43:31Z"}