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Run: Pediatric Pain Scale Age-Appropriate Use Audit

Audit pediatric pain assessments for age-appropriate scale selection, timely documentation, and clear follow-up after intervention. Use it to catch mismatche...

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Audit Details

Record the patient age in months or years as documented in the chart.
Determine whether the chart includes developmental status, verbal ability, or another basis for selecting a pain scale.
Select the encounter setting reviewed.
Document the date and time of the pain assessment being audited.

Age-Appropriate Pain Scale Selection

Confirm the documented scale is appropriate for the patient’s age and developmental level. Use observational tools such as FLACC for younger or nonverbal children and self-report tools such as Wong-Baker FACES when the child can reliably self-report.
If the patient is an infant, toddler, preschool-age child, or otherwise unable to reliably self-report, verify that FLACC or another observational scale was used when appropriate.
If the patient is developmentally able to self-report pain, verify that Wong-Baker FACES or another age-appropriate self-report tool was used when appropriate.
The chart should identify the pain tool used by name, not just record a pain score.
Verify the score is documented in the correct format for the selected tool, such as FLACC component-based scoring or a Wong-Baker face score.

Documentation Timeliness

Measure the elapsed time between the clinical event requiring assessment and the documented initial pain score.
Measure the elapsed time between pain intervention and reassessment documentation.
Verify that pain assessment entries include date and time stamps sufficient to establish timeliness.
Confirm the reassessment interval documented in the chart aligns with the facility policy or order set.

Clinical Documentation Quality

Verify the documented scale and score remain consistent across notes, flowsheets, and medication records.
Confirm the chart contains supporting observations or patient statements that justify the selected pain tool.
Verify the record shows whether the intervention improved the patient’s pain score or symptoms.
If a nonstandard scale was used, confirm the chart includes a clear clinical rationale.

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