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Nursing documentation of postoperative pain management
Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Nursing Science.
Health and Caring Sciences, Dalarna University, Falun Campus, Falun, Sweden.
2002 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, Vol. 11, no 6, 734-742 p.Article in journal (Refereed) Published
Abstract [en]

• Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. • The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. • The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. • The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. • The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. • The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware. © 2002 Blackwell Science Ltd.

Place, publisher, year, edition, pages
2002. Vol. 11, no 6, 734-742 p.
Keyword [en]
Nursing, Pain, Patient records, Postoperative, Record audit
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-46881DOI: 10.1046/j.1365-2702.2002.00688.xOAI: oai:DiVA.org:liu-46881DiVA: diva2:267777
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2011-01-13

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Idvall, Ewa

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CiteExportLink to record
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Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
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  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf