NR 642 Week 7 Baseline Measurement Plan Example

Baseline Measurement Plan: The PRN Reassessment Measure Written in the Record's Own Terms, a Test Pull From One Week and What the Field Can Never See

Student Name

College of Nursing, Chamberlain University

NR 642: Informatics Nurse Specialist Concluding Graduate Experience I

Instructor Name

Month Day, Year

Baseline Measurement Plan: The PRN Reassessment Measure Written in the Record's Own Terms, a Test Pull From One Week and What the Field Can Never See

The Measure, Written for a Stranger

Numerator: PRN opioid administrations in the population below for which a value is filed in the flowsheet row "Pain Reassessment" (row group "Pain Reassessment," pain flowsheet), in either its pain score field or its "Patient asleep, not disturbed" option, with a "taken" time no earlier than the administration time and no later than 30 minutes after it for intravenous doses or 60 minutes after it for all other routes.

Denominator: all PRN opioid administrations in the population.

Companion measure: the same administrations for which no Pain Reassessment value exists in the window but a value is filed in the row "Pain Score" of the routine group "Pain Assessment" in the same window. This measures documentation landing in the wrong row.

The Population, as Rules a Report Can Apply

Include: medication administration actions recorded as "Given"; order frequency containing "PRN"; medication in the pharmacy grouper "Opioid analgesics, PRN reassessment list," agreed between the pain committee chair and pharmacy informatics; route oral or intravenous; administering department one of the two medical-surgical units or the orthopedic unit; patient age 18 or older.

Exclude: patient-controlled analgesia and continuous infusion orders; transdermal and epidural routes; actions "Held," "Refused" or "Not given"; administrations in the post-anesthesia unit, even if the patient later transferred; and cough preparations containing codeine, which are not on the reassessment list.

The Source and the Wait

Source: the warehouse tables for medication administrations and flowsheet values, using the quality analyst's existing quarterly query as the base. The project does not need a new report built; it needs the existing query run on a weekly window and the companion measure added as a second column. The quality analyst estimated two hours to adapt the query.

The wait: report requests normally join a queue of four to six weeks. Because the analyst adapted an existing query rather than building a new one, and the pain committee chair asked for it, the adaptation was done on 16 October. That will not be true of later changes, which the plan budgets at six weeks.

The Test Pull

Run on 19 October with the student's time-limited reporting role, for the week of 21 to 27 September 2026.

Result: 702 PRN opioid administrations in the population. Pain Reassessment row inside the window: 401 (57%). Companion measure, routine row only: 96 (14%). Neither: 205 (29%).

Does it resemble the world? The student checked 20 of the 702 administrations against the chart in the record. Nineteen agreed with the pull. The one disagreement was a dose given in the post-anesthesia unit, which the pull counted as given on the receiving unit because the administering department field was filled with the patient's later location. The analyst changed the rule to use the department at the time of administration, and the corrected pull gave 699 administrations with the same percentages to the nearest point.

The 57% matches the quarterly report for July to September, which gives confidence that the adapted query reproduces the committee's figure.

What the Pull Did Not Test

The test pull confirmed the population rules and the match to the chart. It did not test how the measure behaves when the trigger list changes, since the agreed list was not yet final on 19 October; the pull used pharmacy's existing opioid grouper with codeine cough preparations removed by hand. When the agreed list is final, the pull will be rerun on the same week to confirm the counts move only slightly, and any larger movement will be explained before the baseline is fixed. It also did not test the night shift separately; a split by shift will be added to the weekly output so that differences between day and night documentation can be seen, along with a split by unit.

Baseline Window

Twelve weeks, 6 July to 27 September 2026, run weekly. Twelve points give a run chart median and enough points to judge a later shift. The baseline ends before the November upgrade, so no system change falls inside it.

What the Field Never Sees

Reassessments filed in free-text notes; about 5 of 60 in the September audit. Reassessments done at the bedside but not filed until after the window, which the "taken" time may or may not reflect. Whether the reassessment was clinically appropriate. Whether pain was relieved. Night shift patterns, which are in the data but have not been observed.

What Caps the Measure

Data quality limits what the measure can show. The "taken" time is editable, so a nurse filing late can set it to the bedside time, or not. Completeness, correctness and timeliness are all dimensions of data quality that matter for reuse (Weiskopf & Weng, 2013), and this measure depends on all three.

Size of difference it can register: with about 700 administrations a week, a change of three to four percentage points in a weekly figure is outside normal week-to-week variation in the baseline, which ranged from 54% to 60%. A change only in where documentation lands, from the routine row to the reassessment row, would show as a rise in the main measure and a fall in the companion measure of similar size.

How Weekly Results Will Be Read

Each week's two figures go on run charts with the 12-week baseline median drawn across. A shift, six or more consecutive weeks above the median, would be read as a real change. Single high weeks will not be. The companion measure is read together with the main one: if both rise, documentation in total has increased; if one rises as the other falls, documentation has moved rows. Electronic pain records have shown reassessment data split across fields in ways that confuse evaluation (Samuels & Kritter, 2011), which is why the companion measure exists.

Who Can Run It Later

The quality analyst, on a weekly schedule, with output to the pain committee chair and the clinical informatics manager. The student's reporting role ends on 13 December; nothing depends on it after that.

Fit With Published Practice

Projects that improved reassessment documentation used reports that made gaps visible quickly (Israel et al., 2023). A weekly run of the adapted query does the same.

References

Israel, S., Perazzo, S., Lee, M., Samson, R., Safari-Ferra, P., Badh, R., Abera, S., & Soghier, L. (2023). Improving documentation of pain reassessment after pain management interventions in the NICU. Pediatric Quality & Safety, 8(5), e688. https://doi.org/10.1097/pq9.0000000000000688

Samuels, J. G., & Kritter, D. (2011). Pain management documentation: Analyzing one hospital's computerized clinical records. CIN: Computers, Informatics, Nursing, 29(9), 512-518. https://doi.org/10.1097/NCN.0b013e31821a1582

Weiskopf, N. G., & Weng, C. (2013). Methods and dimensions of electronic health record data quality assessment: Enabling reuse for clinical research. Journal of the American Medical Informatics Association, 20(1), 144-151. https://doi.org/10.1136/amiajnl-2011-000681