Pain Audit Tools (PAT)

Abstract

The Pain Audit Tools (PAT) constitute a specialized set of instruments developed by the City of Hope Pain & Palliative Care Resource Center. These tools are designed to facilitate Quality Assurance (QA) and educational initiatives aimed at improving pain assessment and management, particularly within settings providing palliative care for patients suffering from a terminal illness. The PAT system is composed of three distinct surveys: an 11-item Chart Audit Form used for institutional data collection, a 17-item Patient Pain Interview (self-report), and a specialized Chart Review form tailored for surgical reviews.

Keywords

Pain Audit Tools, PAT, Pain Management, Quality Assurance, Palliative Care, Oncology, Nursing Audit, Patient Interview, Chart Review, Pain Assessment.

Authors

City of Hope Pain & Palliative Care Resource Center; Betty R. Ferrell, RN, PhD, FAAN (Research Scientist, Nursing Research and Education).

Purpose

The primary purpose of the Pain Audit Tools (PAT) is twofold: to serve as a comprehensive quality assessment tool and to function as an educational resource for healthcare providers, especially nurses, involved in pain management. By systematically auditing patient records and interviewing patients, the PAT identifies gaps in current pain care practices and documentation, thereby maintaining a high standard of care and allowing necessary improvements to be made.

Specifically, the tools are used to gather detailed information across three critical areas: institutional compliance with prescribed pain protocols (Chart Audit), the patient’s subjective experience of pain and treatment satisfaction (Patient Interview), and the efficacy of pain management within specialized surgical settings (Surgical Review Audit). The data collected helps institutions, such as the City of Hope Medical Center where the tool originated, to improve compliance with prescribed medications and ensure appropriate follow-up evaluation, aligning with standards set by accreditation bodies like JCAHO.

Construct

The PAT primarily measures the construct of Quality of Pain Management Care within a clinical setting, rather than a single psychological trait. This overarching construct is evaluated through several sub-domains:

• Documentation Compliance: Assessing whether required elements of pain assessment (e.g., objective ratings, follow-up evaluations) are consistently recorded in the patient chart.
• Patient Experience and Satisfaction: Capturing the patient’s self-reported pain intensity, symptom burden (constipation, nausea, drowsiness), and satisfaction with current treatment modalities.
• Treatment Efficacy and Adherence: Comparing prescribed medication regimens against the patient’s actual consumption patterns and identifying barriers to effective pain relief (e.g., cost, fear of addiction).

Validity

Formal, quantitative reports regarding the statistical validity (e.g., construct, criterion, or predictive validity) of the PAT instruments are not explicitly detailed in the provided source material. However, the tools exhibit strong face validity and content validity, as they were developed specifically by experts at the City of Hope Pain & Palliative Care Resource Center to align with established best practices in pain management and quality standards for palliative care settings.

The tool’s design ensures that essential components of comprehensive pain care, such as charting objective ratings (visual analogues, rating scales) and follow-up evaluations, are systematically reviewed. The comparison between the Chart Audit (Item 7) and the Patient Interview (Item 14) serves as an internal check for discrepancies between prescription orders and patient self-reported intake, highlighting a key area for quality improvement.

Reliability

Specific internal consistency measures (e.g., Cronbach’s alpha) or test-retest reliability scores for the PAT instruments are not furnished in the accompanying documentation. Given that the PAT functions largely as an audit checklist and structured interview guide for Quality Assurance, reliability relies heavily on the standardization of the audit process and the training of the administering staff (nurses and interviewers).

Reliability in chart review components (Chart Audit Form and Surgical Review Form) is dependent on the clarity of documentation standards within the institution. The Patient Pain Interview component, utilizing standard 0-10 numerical rating scales for pain intensity and symptoms, benefits from the established reliability of these conventional pain measures.

Factor Analysis

The Pain Audit Tools are structured as a multi-component system (three distinct surveys) designed for comprehensive institutional review rather than as a single, unidimensional psychological scale. Therefore, standard exploratory or confirmatory factor analysis is not applicable to the overall PAT system. The individual components—Chart Audit, Patient Interview, and Surgical Review—focus on distinct aspects of quality care delivery and documentation, functioning as separate audit modules.

Instrument

Test Type: Audit and Structured Patient Interview Instrument (Quality Assessment and Educational Tool)

Format: Three separate paper-based surveys/forms (Chart Audit Form: 11 items; Patient Pain Interview: 17 items; Surgical Service Chart Review Form: variable items).

Language Available: English (Original documentation).

Population Group: Healthcare institutions and their staff (for audit purposes); patients receiving pain management, often in oncology and palliative care settings.

Age Group: Adult patients capable of self-reporting pain and symptom severity.

Population Details: Originally developed for the City of Hope oncology population, but explicitly designed to be modifiable for other patient groups (e.g., surgical patients, non-cancer patients).

Test Methodology: Chart review performed by nursing staff (Chart Audit Forms) and confidential self-report survey administered to patients (Patient Pain Interview).

Keywords

Pain Audit Tools, Nursing Quality, Patient Safety, Symptom Management, Pain Relief, Clinical Audit, Healthcare Metrics, JCAHO Standards.

Authors

Author ORCID Identifier: N/A

Affiliation Email addresses: N/A

Correspondence Address: Betty R. Ferrell, RN, PhD, FAAN, Nursing Research and Education, City of Hope National Medical Center.

Permissions & Fee and Test Year

The Pain Audit Tools were developed and used by the City of Hope Medical Center. The provided documentation (dated 2/98) suggests the forms were available for use by colleagues. Permissions and current fee structure must be confirmed directly with the City of Hope Pain & Palliative Care Resource Center. The referenced articles confirming the use of these tools date back to the early 1990s (1991, 1992), indicating the tool’s initial development and application period.

Reference’s

1. City of Hope Pain & Palliative Care Resource Center. Research Instruments/Resources. City of Hope Pain & Palliative Care Resource Center. Retrieved October 27, 2012, from https://prc.coh.org/res_inst.asp

2. Ferrell, B., Wisdom, C., Rhiner, M., and Alletto, J. (1991). Pain management as a quality of care outcome. Journal of Nursing Quality Assurance, 5(2), 50-58.

3. Ferrell, B, McCaffery, M., and Ropchan, R. (1992). Pain Management as a Clinical Challenge for Nursing Administration. Nursing Outlook, 40(6), 263-268.

Items of the Pain Audit Tools (PAT)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

CHART AUDIT

Subject #

Medical Record #

Interviewer Initials

Date

1. Patient Setting/Unit

2. Patient Diagnosis

____________________________________________________________________________________________________

3. Disease Status:   Cancer/Active Treatment

    Cancer/Remission

    Cancer/Palliative Care

    Other than cancer

4. Current Treatments

         Radiation      Chemo      Surgery       Other (List)

____________________________________________________________________________________________________

5. Reason for Admission/Visit

_______________________________________________________________________________________________________

6. Admitting Medical Service

____________________________________________________________________________________________________

Chart Review

7. What is currently prescribed for the patient’s pain?

8. Is there evidence of use of objective ratings (i.e. visual analogues, rating scales, pain tools)?

  No         Yes

(If yes identify both the rater and rating, example: “0-5 rating scale in nurse’s notes”)

9. Documented descriptions of pain other than objective ratings for the previous 24-hour period. If present, specify rater and description. (Example: “Physicians progress report says “Pain better.”)

10. Has a follow-up evaluation been charted for:

Medications: Yes No Other Modalities Yes No

11. Is pain assessment reflected in:

Last MD Progress Note: Yes No

Other: Yes No

PATIENT PAIN INTERVIEW

Your comfort is very important to us. We would appreciate your input on the following survey so that we might learn how to better relieve your pain. Your answers to this survey will remain confidential. Your participation is completely voluntary.

1. Your Age   2.       Male    Female

3. Your Diagnosis

4. When was your cancer first diagnosed?   Month    Year

5. When did your pain first begin?     Month    Year

6. Who writes the prescriptions for your pain medications? (List doctors’ names)

____________________________________________________________________________________________________________________________________________________

Please answer the following questions by circling the one number on each line that best describes your pain or other symptoms.

7. How much pain do you have right now?

0 1 2 3 4 5 6 7 8 9 10

No Pain                          Pain As Bad As You Can Imagine

8. Over the past 24 hours, what is the average amount of pain you have had?

0 1 2 3 4 5 6 7 8 9 10

No Pain                          Pain As Bad As You Can Imagine

9. What is the worst amount of pain you have had in the last week?

0 1 2 3 4 5 6 7 8 9 10

No Pain                          Pain As Bad As You Can Imagine

10. Do you have a problem with constipation?

0 1 2 3 4 5 6 7 8 9 10

No Pain                          Pain As Bad As You Can Imagine

11. Do you have nausea?

0 1 2 3 4 5 6 7 8 9 10

No Pain                          Pain as Bad as You Can Imagine

12. Do you have a problem with drowsiness or sleepiness from your medication?

0 1 2 3 4 5 6 7 8 9 10

Never                        All the Time

13. How satisfied are you overall with the current treatment you are receiving for your pain?

0 1 2 3 4 5 6 7 8 9 10

Not At All Satisfied                     Very Satisfied

14. What medicines are you taking for pain? Please list.

15. Which of the following influence or interfere with your pain management? (Check all that apply.)

• Money to pay for pain medications.
• Communicating or explaining your pain to others.
• Coming in to pick up prescriptions.
• Being afraid of being addicted to pain medicines.
• Side effects of pain medicine.
• Concern that I should save some pain medicine in case my pain gets worse.
• Other (Describe)

____________________________________________________________________________________________________

16. Are you seeing any specialists for help with your pain? (Check any that apply.)

• Anesthesia      Physical Therapy      Pain Team
• Neurology    Psychologist      Occupational Therapy
• Radiation    Other (Describe)

17. Are you using anything other than medicines for your pain?

• Cold    Massage
• Heat    Relaxation
• Imagery    TENS Unit
• Other (Describe)

Please write any other information you would like to share on the back of this survey. Thank you for your help.

Medical Record # Pt. Completed Area Interviewed

CITY OF HOPE NATIONAL MEDICAL CENTER

Chart Review

METHODS: Nursing staff to complete on day of discharge.

1. Patient setting:

2. Patient diagnosis

• Primary surgical:
• Primary medical:
• Other medical:

3. Cause of pain:

4. Surgical procedures

Abdominal:

•  Gastric, subtotal w/ bypass
•  Gastric, total w/ bypass
•  Gastric, other specify
•  Colon, hemicolectomy w/ colostomy
•  Colon, hemicolectomy w/ primary anastomosis
•  Colon, other, specify
•  Rectal, abdominal- perineal resection, w/ colostomy
•  Rectal, abdominal- perineal w/low anastamosis
•  Rectal, other, specify
•  Pancreatic, whipple procedure
•  Pancreatic, biopsy w/ bypass
•  Pancreatic, other, specify

Breast

•  Mastectomy
•  Lumpectomy
•  Axillary node dissection

Chart Review Medical Record #

Page 2 Pt. Completed Area Interviewed

Gynecologic:

•  Ovarian, TAH/BSO
•  Corpus uteri, TAH/BSO
•  Cervix uteri, TAH/BSO
•  Vulva, Radical vulvectomy
•  Pelvic exenteration
•  Other

Disease Status :

•  Active treatment
•  Remission
•  Palliative

5. Date of surgery:

6. Date of first ambulation:

7. Complications:  Pneumonia

 Wound infection

8. Prior substance abuse history:  Alcohol                   (taken from H&P)  Narcotics

 Other

9. Is there evidence of use of objective ratings (i.e. visual analogues, rating scales, pain tools)?

 No  Yes Rater                                                    , rating

10. Are there documented descriptions of pain other than objective ratings for the previous 24-hour period?

 No  Yes Rater

Description

DOCUMENTATION:

11. Has a follow-up evaluation been charted for: Medications:  Yes  No

Other modalities:  Yes  No

Chart Review Medical Record #                                   

Page 3 Pt. Completed                Area                

Interviewed    

12. Is pain assessment reflected in:

RN Admission/HX:  Yes  No RN Notes-Last 24 hrs  Yes  No RN Care plan:  Yes  No MD H&P  Yes  No Last MD progress  Yes  No Other:  Yes  No

13. Perioperative pain medications: