Graduation Semester and Year
Summer 2026
Language
English
Document Type
DNP Project
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Cathy Brown
Second Advisor
Yungefi Kao
Abstract
Purpose: This guideline-directed project aimed to increase registered nurse (RN) compliance with documenting pain reassessment in an adult medical-surgical unit at an acute care facility.
Background: Proper documentation is crucial for clinical decision-making and legal and ethical reasons. The Joint Commission (TJC) has standardized pain documentation requirements to ensure consistent assessment, recording, and management across healthcare settings. Non-compliance can lead to misdiagnosis, inadequate treatment, patient dissatisfaction, and legal consequences. Accreditation bodies audit medical records, and non-compliance may result in penalties, financial losses, or loss of accreditation. Adherence is a clinical best practice and strategic necessity for healthcare organizations. Methodology: A literature review was conducted to identify evidence that met the inclusion criteria. Evidence was graded and four evidence-based interventions were rated by 22 stakeholders. Results: The stakeholders’ recommendations were analyzed. The recommendations including staff education, chart audits/feedback, and timed reminders were rated as significant by the stakeholders. Although patient satisfaction showed promise, the results fell short of the standards established in this project. Conclusion: The project’s objectives aligned with graded evidence-based recommendations and ratings, leading to the development of a novel intervention guideline to improve compliance in pain reassessment and documentation. The collected data provided a promising foundation for a guideline-directed intervention that can be implemented by all future facilities to effectively address TJC standards and achieve accreditation.
Keywords: Joint Commission, requirements, pain reassessment, pain compliance, nursing, staff education, timed reminders, chart audits, feedback, patient satisfaction
Keywords
Joint Commission, requirements, pain reassessment, pain compliance, nursing, staff education, timed reminders, chart audits, feedback, patient satisfaction
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Jones, Kriss S., "Increasing Compliance in Pain Reassessment and Documentation in an Acute Care Facilityy" (2026). Doctor of Nursing Practice (DNP) Scholarly Projects. 11.
https://mavmatrix.uta.edu/nursing_dnpprojects2/11