Abstract
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.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 279-284 |
| Number of pages | 6 |
| Journal | Journal of Nursing Care Quality |
| Volume | 34 |
| Issue number | 3 |
| DOIs | |
| State | Published - Jul 1 2019 |
| Externally published | Yes |
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Keywords
- documentary analysis
- documentation
- nursing
- pain management
- postoperative care
ASJC Scopus subject areas
- Nursing(all)
Cite this
Nursing Documentation of Postoperative Pain Management : A Documentary Analysis. / Shoqirat, Noordeen; Mahasneh, Deema; Dardas, Latefa; Singh, Charleen; Khresheh, Reham.
In: Journal of Nursing Care Quality, Vol. 34, No. 3, 01.07.2019, p. 279-284.Research output: Contribution to journal › Article
}
TY - JOUR
T1 - Nursing Documentation of Postoperative Pain Management
T2 - A Documentary Analysis
AU - Shoqirat, Noordeen
AU - Mahasneh, Deema
AU - Dardas, Latefa
AU - Singh, Charleen
AU - Khresheh, Reham
PY - 2019/7/1
Y1 - 2019/7/1
N2 - 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.
AB - 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.
KW - documentary analysis
KW - documentation
KW - nursing
KW - pain management
KW - postoperative care
UR - http://www.scopus.com/inward/record.url?scp=85066397449&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85066397449&partnerID=8YFLogxK
U2 - 10.1097/NCQ.0000000000000372
DO - 10.1097/NCQ.0000000000000372
M3 - Article
C2 - 30480613
AN - SCOPUS:85066397449
VL - 34
SP - 279
EP - 284
JO - Journal of Nursing Care Quality
JF - Journal of Nursing Care Quality
SN - 1057-3631
IS - 3
ER -