Policy Manual sample

MDT Home Health Care Agency, Inc. 159 • At regular intervals, as appropriate, while the patient is receiving care, treatment and/or services through MDT Home Health Care Agency, Inc. based upon the patient’s clinical status • Whenever a patient self-reports pain • The assessment and measure of pain intensity and quality, i.e., pain character, frequency, location and duration, should be appropriate to the patient’s age. • Elements addressed in a comprehensive pain assessment include, but are not limited to: • Description, duration, variations and intensity of pain using an Agency-approved pain intensity rating scale appropriate to the patient’s age, cognitive and learning abilities • Location of pain and radiation, if any • Circumstances of the onset of pain • Aggravating/alleviating factors • Present pain management regimen and its effectiveness • Previous pain management interventions and the effectiveness of those interventions • Impact of pain on the patient’s quality of life, i.e., impact on activities of daily living, sleep, appetite, relationships with others, emotions, concentration • Pain management history, including medication history, presence of barriers to reporting pain and using analgesics and/or complementary therapies, manner of expressing pain • Patient’s and family’s pain management goals • The Registered Nurse/Therapist: • Formulates, implements and updates the pain management plan of care based on assessment findings in collaboration with the patient/family and communicates this plan to other members of the healthcare team. • Assesses the patient’s pain and evaluates his/her response to pain management interventions using a standard pain management tool based on the patient’s self-report during each visit. • Assesses the patient for adequate pain control, bowel elimination, change in level of consciousness/cognitive function, general behavior, social interactions and nutritional status.