Development and validation of standardized pain management documentation

Abstract

Pain management, assessment and documentation is a crucial part of patient care. However, several studies show flaws in pain management processes. Documentation is not unified or even sufficient. The aim of this study was to describe how patient pain management has been recorded using the nursing diagnoses and nursing interventions of a standardized terminology, the Finnish Care Classification, (FinCC), and how that terminology should be further developed. The research data consisted of the daily nursing documentation notes of patient care episodes (n=806) during inpatient days (n=2564) at several specialty units (n=9). The documentation of pain management was found inadequate and insufficient. The results support the development of a new component, Pain management, and its attendant categories in the new version, FinCC 4.0, to help nurses document pain management in their daily work.