Dissertation
Improving pain screen documentation compliance using audit-feedback in an intermediate care unit
Doctor of Nursing Practice (D.N.P.), Drexel University
16 Mar 2026
DOI:
https://doi.org/10.17918/00011327
Abstract
Incomplete pain screening documentation can contribute to communication gaps, delayed interventions, and reduced quality of care in hospitalized patients. Evidence-based literature indicates that audit and feedback strategies can improve documentation practices when feedback is delivered frequently and integrated into routine clinical workflow. Despite established documentation standards, internal audits on a 36-bed Intermediate Care (IMC) unit revealed low compliance with required pain screen documentation. A quality improvement project was implemented to evaluate whether structured audit-feedback could improve pain screen documentation compliance among nurses on the IMC unit. The intervention included bi-weekly pain documentation audits and delivery of audit feedback during routine shift communication, including huddles, charge nurse report, and unit rounding. The project was implemented using iterative Plan-Do-Study-Act (PDSA) cycles, with each audit reviewing 10 patient charts for completeness of required pain screen elements. Compliance rates were monitored across audit cycles to evaluate changes in documentation practices over time. During the project period, pain screen documentation compliance improved from a baseline of 10% to 70% following implementation of the audit-feedback intervention. These findings suggest that integrating structured audit-feedback into routine workflow may improve documentation reliability and support sustainable quality improvement efforts within acute care settings. Keywords: pain screening documentation; audit and feedback; nursing documentation compliance; quality improvement
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Details
- Title
- Improving pain screen documentation compliance using audit-feedback in an intermediate care unit
- Creators
- Shaterra Plummer
- Contributors
- Barbara Ruth Osborne (DNP Chair) - Drexel University, Nurse Practitioner Master of Science in Nursing (MSN)
- Awarding Institution
- Drexel University
- Degree Awarded
- Doctor of Nursing Practice (D.N.P.)
- Publisher
- Drexel University
- Number of pages
- 47 pages
- Resource Type
- Dissertation
- Language
- English
- Academic Unit
- Doctoral Nursing; Nursing (Graduate); College of Nursing and Health Professions; Drexel University
- Other Identifier
- 991022172975804721