title: Pain management documentation quality as a reflection of nurses' clinical judgment.
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.
authors.affiliation: University of New Hampshire, Durham, New Hampshire 03824, USA. Joanne.samuels@unh.edu
authors.forename: Joanne G
authors.initials: JG
authors.lastname: Samuels
authors.forename: Susan
authors.initials: S
authors.lastname: Fetzer
mesh_terms: D000328:Adult; D002983:Clinical Competence; D004282:Documentation / Q000592:standards*; D055318:Evidence-Based Nursing / Q000379:methods; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D007600:Judgment; D008875:Middle Aged; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital / Q000592:standards*; D010146:Pain / Q000451:nursing*; D013527:Perioperative Nursing / Q000592:standards; D011787:Quality of Health Care; D014481:United States