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Abstract

This project aimed to provide a retrospective chart review (RCR) of RN documentation of pain assessments for adult patients aged 19 and older with a heart failure diagnosis who did not receive a surgical intervention requiring general anesthesia within the CVICU. Analysis of documentation was used to create staff education to align documentation to current requirements, increasing documentation practices, with a long-term goal of improving patient pain management and aligning practice to policy, and providing current best practice recommendations.

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