An example of application of Article 7 – Italian Law 38: “Duty to report the recognition pain in the medical record”

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On 15th March 2010 the “Law 38” was issued in Italy. This law was introduced to ensure the citizens’ right of access to palliative care and pain therapy. With the purpose of applying the law, but mainly to correctly identify the breakthrough cancer pain (BTcP) in oncologic patients, we conducted an internal audit in our department, in order to evaluate the minimal data setting to be introduced in the medical record, with the aim to systematically register pain and its episodic severe recurrence. The systematic measurement has identified many patients with poorly controlled baseline pain acceptance (36.5%), at discharge the percentage was reduced (9.5%), but not yet at an ideal level, ie the disappearance of pain. It was also noted that while at the acceptance the percentage of BTcP patients treated with opioids was just 21.2%, at discharge, they increased to 81.3%.The internal audit was also very useful to establish a methodological interaction process between nursing and medical staff.

KEY ­WORDS: audit, breakthrough cancer pain, medical record, oncologic patient

Also available in : Italiano