Chapter 10: Pain Medicine 2026

 Dr Sharmila Khot

Why do this quality improvement project

Chronic pain management involves biopsychosocial assessment of patients in a pain clinic and documenting clinical history, examination details and planned management. Clinical documentation also includes pain history, its impact on mood, sleep and quality of life. Additional documentation of mood including PROMs of anxiety, depression or catastrophising, or quality of life measures such as EQ5D are administered in the pain clinic. History also includes social issues such as relationships, work and other life events or habits. 
Following clinical diagnosis, a comprehensive management plan is discussed with patients and finalised using a shared decision-making approach. Management of chronic persistent pain conditions may include 3rd sector organisation information, e.g. Pain Concern, British Pain Society etc.; targeted treatments for chronic pain, including-medications, invasive and non-invasive medical interventions; further investigations or referrals as indicated; and a plan for review of the patient. Patients are signposted to suitable websites and information documents on an individualised basis, such as QR codes, including medication-related information from the Faculty of Pain Medicine for pain medications and/or interventions.

This project uses process measures to assess and improve documentation.  Complete and legible medical documentation is essential for safe clinical management, accurate recording of consultations, effective communication within the multidisciplinary team and for accountability of healthcare professionals and hospital trusts if a medico-legal issue were to arise.  

Background

Medical records, or health records, and the practice of good record keeping are essential to the provision of healthcare. Without them, it is impossible to diagnose and treat patients reliably and to maintain continuity of care. Health records may also be used as evidence in legal proceedings, as the General Medical Council (GMC) states:
“Medical records are made to support safe and effective care, but they may be used for other purposes. […] They may also be used as evidence in court."

Medical records are also used for administrative and managerial decision making, clinical audit and clinical research. The main purpose of the record is to provide an account of a patient’s contact with the healthcare system.

The GMC Good Medical Practice 2024 provides detailed guidance as to what constitutes complete clinical care. Details of clinical care provided should be suitably documented in order that the care plan for the patient is visible to any other healthcare provider involved in that patient’s care pathway.  Clinicians should "keep clear, accurate, and legible notes, report relevant clinical findings, document decisions made and by whom, document the information given to patients, document any drugs or other treatment prescribed and document who is making the record and when." Notes should be kept safely, in accordance with local data protection guidelines, avoiding any loose pages.

Best Practice

Best Practice is dictated by the legal framework under which this was developed, and the GMC duties of a doctor clearly states that medical record keeping is a fundamental duty.  From a litigation point of view, if there is incorrect or no documentation, even if everything was done correctly, a case is difficult to defend (Abdelrehman and Abdelmageed 2014). Guidance from the Medical Defence Union¹ clearly asks doctors to document each patient interaction as soon as possible and to maintain the integrity of the record

The GMC’s Good Medical Practice guidance on ‘Recording work clearly, accurately, and legibly’.²includes a requirement that doctors must ensure that formal records of their work (including patients’ records) are clear, accurate, contemporaneous and legible. The doctor must take a proportionate approach to the level of detail, but patients’ records should usually include:

a. relevant clinical findings 
b. drugs, investigations or treatments proposed, provided or prescribed.
c. the information shared with patients 
d. concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed 
e. information about any reasonable adjustments and communication support preferences 
f. decisions made, actions agreed (including decisions to take no action) and when/whether decisions should be reviewed 
g. who is creating the record and when.

The GMC’s Decision making and Consent (Nov 2020)³ has further guidance on Recording decisions; Patients’ medical records- recommending the doctor maintain an accurate record of the exchange of information, which leads to a decision in a patient’s record to inform their future care and help the doctor to explain and justify their decisions and actions.

The record of this discussion is to be flagged and made available to the patient and others involved in their care, so everyone is clear about what has been agreed. Any decision or preference should be easy to access and regularly reviewed.⁴

Suggested data to collect

Process measures

•  Proportion of patients where the following were documented: 
  o   A biopsychosocial assessment, including a physical examination
  o    Use of appropriate translation services where the patient is non-English speaking
  o    Pain scores, including documentation of whether pain affected
      a. Quality of life
      b.  anxiety 
      c. depression
  o    Pain management plan documented (Did it include a plan for follow-up or discharge?)
  o    Medications review documented (Was there a plan for de-escalation if needed?)
• Where new medications were prescribed, the proportion of patients with documentation of: 
  o    discussion of side effects 
  o    a defined trial period
  o    Provision of patient information leaflet or signposting
• where an intervention is offered as part of a management plan, the proportion of patients with documentation of: 
  o    discussion covering the indication, risks and expected outcomes 
  o    Provision of patient information leaflet or signposting to the relevant resources.
• Where follow-up after an intervention occurs, the proportion of patients with:  
  o    Documentation of the outcome of the intervention
• Where further investigation or referral is offered, the proportion of patients with:
  o    A documented plan for follow-up after the investigation or referral

•  Proportion of patients with documentation of:

  o Patients were offered education on different aspects of pain, lifestyle changes and social prescribing.

  o Patient expectations and any concerns or apprehensions are being reviewed and addressed.

  o  Patient satisfaction with the documentation provided

Outcome measures: Complaint data where inadequate documentation is identified as a contributing factor

Balancing measures: related to the time taken to document and the ease of utility of documentation tools

QI methodology

•  Involve a stakeholder group in process mapping the pathway to capture as many experiences as possible for documentation in this setting.  Qualitative interviews may be useful in capturing the perceived enablers and barriers to good documentation.  Codesign with patients should be considered regarding documentation in letters.  
• Use process measure data gathered as above to describe current state and identify gaps in the current documentation
• Determine the ways in which the outcomes of your pain clinic are collected, analysed and interpreted. 
  o    Do the data points collected serve their required purpose? 
  o    How is this information disseminated throughout the relevant teams? 
  o    Stakeholder opinions on how to improve this process
• Prioritise gaps and bottlenecks and identify aims utilising a driver diagram to identify drivers
• Utilise a process map to create a model of the areas that may impact the system and where change ideas could be employed.

Plan-do-study-act cycles can be started with potential interventions, including bespoke documents to record clinic reviews on, electronic patient records, or automatic transcription of voice recordings of documentation.  At each test of change, stakeholders should be interviewed on the utility of the tools and the balancing measures interrogated to determine the impact on the system.

References

1 Abdelrahman W and Abdelmageed A (2014) Medical record keeping: clarity, accuracy, and timeliness are essential BMJ;348: f7716 https://www.themdu.com/guidance-and-advice/guides/effective-record-keep… accessed at 06:22 on 22-07-2025
2.The General Medical Council. Good Medical Practice. https://www.gmc-uk.org/professional-standards/the-professional-standard…; Recording your work clearly, accurately, and legibly

3.Decision making and consent – GMC guidance for professional ethics and standards for doctors (Nov 2020) https://www.gmc-uk.org/-/media/documents/updated-decision-making-and-co… accessed on 22-07-2025 at 16:42

4.Backhouse A and Ogunlayi F Quality improvement into practice (2020) BMJ; 368 m865
doi: https://doi.org/10.1136/bmj.m865