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Pain Management Documentation: Analyzing One Hospital's Computerized Clinical Records

SAMUELS, JOANNE G. PhD, RN; KRITTER, DAWN MS, RRT

CIN: Computers, Informatics, Nursing: September 2011 - Volume 29 - Issue 9 - p 512-518
doi: 10.1097/NCN.0b013e31821a1582
Continuing Education

Pain management documentation, consisting of assessment, interventions, and reassessment, can help provide an important means of communication among practitioners to individualize care. Standard-setting organizations use pain management documentation as a key indicator of quality. Adoption of the electronic medical record alters the presentation of pain management documentation data for clinical and quality evaluation use. The purpose of this study was to describe pain management documentation output from the electronic medical record to gain an understanding of its presentation and evaluate the quantity and quality of the output. After institutional review board approval, data were abstracted from 51 electronic records of postsurgical patients in a 100-bed community hospital. Time-variant pain assessments, interventions, and reassessments were organized into pain management episodes to provide clinically interpretable data for evaluation. Data sources were identified. Data generated 1499 episodes for analysis. Analysis of variance results implied that pain management documentation changes with pain severity. Despite legibility and date and time stamping, inconsistencies and omitted and duplicated documentation were identified. Inconsistent data origination posed difficulty for interpreting clinically relevant associations. Improvements are required to streamline fields and consolidate entries to allow for output in alignment with care.

Author Affiliation: Department of Nursing, University of New Hampshire, Durham.

There were no outside sponsors for this work.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Joanne G. Samuels, PhD, RN, Department of Nursing, University of New Hampshire, Hewitt Hall, 4 Library Way, Durham, NH 03824 (joanne.samuels@unh.edu).

© 2011 Lippincott Williams & Wilkins, Inc.