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Nursing Documentation of Postoperative Pain Management

A Documentary Analysis

Shoqirat, Noordeen, PhD; Mahasneh, Deema, PhD, MSc, RGN; Dardas, Latefa, PhD, PMHN; Singh, Charleen, PhD, MSc, RGN, Neuro-SN; Khresheh, Reham, PhD

doi: 10.1097/NCQ.0000000000000372
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Background: Although proper documentation of pain for postoperative patients is essential to promote patient health outcomes, there is limited examination of nurses' documentation of pain management.

Purpose: The purpose of this study was to qualitatively analyze nursing documentation of pain management among postoperative patients in Jordan.

Method: A documentary analysis method was used. A purposive sample of 80 medical records were reviewed, and a total of 720 nursing records were analyzed.

Results: The analysis revealed that nurses' documentation of pain management was limited, vague, incomplete, and largely dependent on their subjective evaluation. Many of the documented goals were broad, not specific, not measurable, and with no time frame.

Conclusions: Documentation patterns revealed a lack of proactive and systematic approach to pain assessment and management. Furthermore, there was little documented evidence of efforts to evaluate the effectiveness of pain management interventions. Findings have important implications for standardizing documentation of pain assessment, intervention, and evaluation.

Adult Health Nursing Department (Drs Shoqirat and Mahasneh), Faculty of Nursing (Dr Khresheh), Mutah University, Karak, Jordan; Department of Community Health Nursing, School of Nursing, The University of Jordan, Amman, Jordan (Dr Dardas); and Betty Irene Moore School of Nursing, Sacramento, California (Dr Singh).

Correspondence: Noordeen Shoqirat, PhD, Mutah University, Karak 61710, Jordan (noorshoq@yahoo.com; noordeen@mutah.edu.jo).

The authors declare no conflicts of interest.

Accepted for publication: September 1, 2018

Published ahead of print: November 21, 2018

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