Keywords

clinical decision making, clinical judgment, documentation, pain management, pain management documentation, pain quality, pain

Authors

1. Samuels, Joanne G. PhD, RN
2. Fetzer, Susan PhD, MBA, RN

Abstract

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.