Pain Management Documentation Quality as a Reflection of Nurses' Clinical Judgment

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.