Pain Management Clinical Documentation Completeness Medical Records Efficiency Pain Documentation Electronic Medical Records Clinical Decision Support System Mobile Applications Randomized Controlled Trial
Conditions
Interventions
Anesthesiology residents document patient care data, clinical progress, and medication details during clinical rounds using traditional paper-based medical records as per the standard protocol of the
Traditional Paper-based Documentation,Mobile-based Decision Support Application
Sponsors
Navamindradhiraj University
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Inclusion criteria
Inclusion criteria: For Patients: 1. Inpatients at the Faculty of Medicine Vajira Hospital who are referred to the Pain Unit. 2. Patients receiving postoperative acute pain management with advanced modalities, including Patient-Controlled Analgesia (PCA), Continuous Epidural Analgesia (CEA), or Peripheral Nerve Blocks. 3. Aged 18 years and older. For Residents: 1. Anesthesiology residents currently rotating at the Pain Unit, Department of Anesthesiology, Vajira Hospital.
Exclusion criteria
Exclusion criteria: For Patients: 1. Patients with severe communication barriers, such as delirium, dementia, or hearing/speech impairments that prevent accurate pain score assessment. 2. Intubated patients receiving sedatives at a level that impairs effective communication. 3. Refusal to provide informed consent or voluntary withdrawal from the study. For Residents: 1. Refusal to provide informed consent or voluntary withdrawal from the study.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Completeness of patient care documentation At the end of each patient clinical round A checklist scoring system based on standard clinical quality criteria of the Pain Unit | — |
Secondary
| Measure | Time frame |
|---|---|
| Data accuracy At the end of each patient clinical round Audit of calculation errors in Morphine Equivalent Daily Dose (MEDD) and medication transcription discrepancies,Documentation time During each patient clinical round Time spent per round measured in minutes,User satisfaction and usability experience At the end of the rotation period Evaluated by anesthesiology residents using the System Usability Scale (SUS) and a clinical usability questionnaire | — |
Countries
Thailand
Contacts
Public ContactNatcharee Ongkanchana
Faculty of Medicine Vajira Hospital, Navamindradhiraj University
Outcome results
None listed