Postoperative pain documentation in a hospital setting: A topical review

Postoperative pain documentation in a hospital setting: A topical review AbstractBackground and aimsNursing documentation supports continuity of care and provides important means of communication among clinicians. The aim of this topical review was to evaluate the published empirical studies on postoperative pain documentation in a hospital setting.MethodsThe review was conducted through a systematic search of electronic databases: Web of Science, PubMed/Medline, CINAHL, Embase, Ovid/Medline, Scopus and Cochrane Library. Ten studies were included. Study designs, documented postoperative pain information, quality of pain documentation, reported quality of postoperative pain management and documentation, and suggestions for future research and practice improvements were extracted from the studies.ResultsThe most commonly used study design was a descriptive retrospective patient record review. The most commonly reported types of information were pain assessment, use of pain assessment tools, useof pain management interventions, reassessment, types of analgesics used, demographic information and pain intensity. All ten studies reported that the quality of postoperative pain documentation does not meet acceptable standards and that there is a need for improvement. The studies found that organization of regular pain management education for nurses is important for the future.ConclusionsPostoperative pain documentation needs to beimproved. Regular educational programmes and development of monitoring systems for systematic evaluation of pain documentation are needed. Guidelines and recommendations should be based on the latest research evidence, and systematically implemented into practice.ImplicationsComprehensive auditing tools for evaluation of pain documentation can make quality assessment easier and coherent. Specific and clear documentation guidelines are needed and existing guidelines should be better implemented into practice. There is a need to increase nurses’ knowledge of postoperative pain management, assessment and documentation. Studies evaluating effectiveness of high quality pain documentation are required. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Scandinavian Journal of Pain de Gruyter

Postoperative pain documentation in a hospital setting: A topical review

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Publisher
De Gruyter
Copyright
© 2015 Scandinavian Association for the Study of Pain
ISSN
1877-8860
eISSN
1877-8879
D.O.I.
10.1016/j.sjpain.2015.12.010
Publisher site
See Article on Publisher Site

Abstract

AbstractBackground and aimsNursing documentation supports continuity of care and provides important means of communication among clinicians. The aim of this topical review was to evaluate the published empirical studies on postoperative pain documentation in a hospital setting.MethodsThe review was conducted through a systematic search of electronic databases: Web of Science, PubMed/Medline, CINAHL, Embase, Ovid/Medline, Scopus and Cochrane Library. Ten studies were included. Study designs, documented postoperative pain information, quality of pain documentation, reported quality of postoperative pain management and documentation, and suggestions for future research and practice improvements were extracted from the studies.ResultsThe most commonly used study design was a descriptive retrospective patient record review. The most commonly reported types of information were pain assessment, use of pain assessment tools, useof pain management interventions, reassessment, types of analgesics used, demographic information and pain intensity. All ten studies reported that the quality of postoperative pain documentation does not meet acceptable standards and that there is a need for improvement. The studies found that organization of regular pain management education for nurses is important for the future.ConclusionsPostoperative pain documentation needs to beimproved. Regular educational programmes and development of monitoring systems for systematic evaluation of pain documentation are needed. Guidelines and recommendations should be based on the latest research evidence, and systematically implemented into practice.ImplicationsComprehensive auditing tools for evaluation of pain documentation can make quality assessment easier and coherent. Specific and clear documentation guidelines are needed and existing guidelines should be better implemented into practice. There is a need to increase nurses’ knowledge of postoperative pain management, assessment and documentation. Studies evaluating effectiveness of high quality pain documentation are required.

Journal

Scandinavian Journal of Painde Gruyter

Published: Apr 1, 2016

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