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Pain Management Documentation Quality as a Reflection of Nurses' Clinical Judgment

Samuels, Joanne G. PhD, RN; Fetzer, Susan PhD, MBA, RN

doi: 10.1097/NCQ.0b013e318194fcec

Pain management documentation (PMD) is the chief method used by administrators, surveyors, and quality improvement managers to measure the quality of pain management. Eighty-five nurses from 2 hospitals generated 340 PMD record entries, which were scored using the Samuels PMD Rating Scale. Nurses' PMD scores ranged from 2.5 to 6.5 (SD = 0.77). Less than 50% of the entries met Joint Commission standards. Documentation results may reflect nurses' pain management clinical judgment. Targeted interventions are recommended.

University of New Hampshire, Durham, New Hampshire.

Corresponding Author: Joanne G. Samuels, PhD, RN, 253 Hewitt Hall, University of New Hampshire, Durham, NH 03824 (

Accepted for publication: June 19, 2008

© 2009 Lippincott Williams & Wilkins, Inc.