Adequacy of pain assessment documentation in older people – Can we do better?

Abstract

Background: Pain is common in older people causing disability, reduced mobility, and poor quality of life.
Objective: Baseline audit of pain assessment documentation in older patients in a tertiary hospital in Brunei Darussalam.
Methods: Retrospective review of electronic health records for inpatients and outpatients for older patients aged 65 years and older under Geriatric Medicine and Orthopaedics.
Results: There were 30 patients with median age of 75 years. The main aspects that require improvement are documented descriptors and severity of pain, side effects of medication, analgesia taken and review of response to analgesia.
Conclusion: The importance of pain assessment and documentation should be emphasized to clinical staff. Availability of localized tools and training sessions may be required.