Postoperative pain documentation in a hospital setting: A topical review

Nursing documentation supports continuity of care and provides important means of communication among clinicians. The aim of this topical review was to evaluate the published empirical studies on postoperative pain documentation in a hospital setting.

The review was conducted through a systematic search of electronic databases: Web of Science, PubMed/Medline, CINAHL, Embase, Ovid/Medline, Scopus and Cochrane Library. Ten studies were included. Study designs, documented postoperative pain information, quality of pain documentation, reported quality of postoperative pain management and documentation, and suggestions for future research and practice improvements were extracted from the studies.

The most commonly used study design was a descriptive retrospective patient record review. The most commonly reported types of information were pain assessment, use of pain assessment tools, use of pain management interventions, reassessment, types of analgesics used, demographic information and pain intensity. All ten studies reported that the quality of postoperative pain documentation does not meet acceptable standards and that there is a need for improvement. The studies found that organization of regular pain management education for nurses is important for the future.

Postoperative pain documentation needs to be improved. Regular educational programmes and development of monitoring systems for systematic evaluation of pain documentation are needed. Guidelines and recommendations should be based on the latest research evidence, and systematically implemented into practice.

Comprehensive auditing tools for evaluation of pain documentation can make quality assessment easier and coherent. Specific and clear documentation guidelines are needed and existing guidelines should be better implemented into practice. There is a need to increase nurses' knowledge of postoperative pain management, assessment and documentation. Studies evaluating effectiveness of high quality pain documentation are required.