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Nursing documentation of postoperative pain management
1Department of Medicine and Care, Division of Nursing Science, Faculty of Health Sciences, Linköping University, Linköping and Västervik Hospital, Västervik, Sweden. evaid@ltkalmar.se
Journal of Clinical Nursing
|November 13, 2002
Summary
Registered nurses in Sweden often failed to systematically document postoperative pain management, despite legal obligations. Many nurses inaccurately believed their pain documentation practices met current regulations and guidelines.
Area of Science:
- Nursing
- Pain Management
- Healthcare Documentation
Background:
- Nursing documentation of pain assessment and treatment is frequently inadequate.
- In Sweden, comprehensive documentation of patient care, including pain assessment, is a legal requirement.
Purpose of the Study:
- To evaluate nursing documentation of postoperative pain management.
- To assess nurses' perceptions of their pain documentation against Swedish regulations and guidelines.
Main Methods:
- A review of nursing records for 172 postoperative patients (second postoperative day).
- Auditing of records using three instruments based on pain management guidelines.
- Surveys of 63 registered nurses regarding documentation compliance.
Main Results:
- Pain assessment relied primarily on patient self-report; less than 10% of records used systematic pain assessment instruments.
- Pain location was documented in 50% of records, and pain character in only 12%.
- Despite documentation gaps, 73% of nurses believed their records complied with regulations.
Conclusions:
- Significant deficiencies exist in nursing documentation of postoperative pain management.
- Nurses were largely unaware of the extent of flaws in their pain documentation practices.
- There is a need for improved education and adherence to pain documentation standards in nursing practice.