Policies and Standards

• M-55
  Medication Administration and Errors
  Pain medications should be administered according to the level of pain
• M-12
  Diagnostic, Therapeutic and Standing Orders
  PRN pain medication orders need qualifiers (mild, moderate, severe) when more than one medication or doses are ordered.
• M- 140
  Pain Management
  Pain management is best achieved through relationships, and should take into account pharmacologic and non-pharmacologic interventions
• R-24
  Controlled Substance Management
  Use of substances often used for pain management.
• M-107
  Interdisciplinary Assessment and Reassessment of Patients
  Initial and ongoing patient assessment should include pain and symptom management.
• M-20
  Discharge Planning/Continuity of Patient Care
  Communication about pain management should be included when a patients is discharged to a skilled nursing facility.
• M-132
• Palliative Sedation
  This is available for terminally ill patients who meet criteria.
• M-139
  Information and Counseling for Terminal Illness
  Patients have the right to comprehensive pain and symptom management.
• P-1
  Patients’ Rights and Responsibilities
  The patient has the right to receive information about treatments for pain relief and participate in pain management decisions, and they have the right to refuse one or all pain treatment modalities.
• M-86
  Procedure Related Sedation (PRS) and Anesthesia
  Pain is one of the elements assessed and managed during sedation.

Joint Commission Standards

CMS Pain Management - CMS Roadmap to Address the Opioid Epidemic