Documentation for Assessing Pain in Postoperative Pain Management Pre- and Post-intervention.

Purpose: Although Norwegian law requires the documentation of patients' care processes, including pain assessment, research has shown that the quality of postoperative documentation for assessing pain does not meet an acceptable standard and requires improvement. The purpose of this study was to investigate whether an educational intervention can increase nurses' documentation of postoperative pain assessments, alter patients' opioid consumption, and ensure that patients have at least one documented Numeric Rating Scale (NRS) <= 3 at rest before being discharged. A secondary aim was to investigate whether the nurses' edu-cation and experience influenced their pain assessments.Design: An observational study with a pre-post intervention. Methods: The study following a pre-post design involved documenting pain assessments of 304 patients undergoing cancer surgeries in a postoperative unit at the Norwegian Radium Hospital, Oslo University Hos-pital. In an educational intervention, two 45-minutes teaching sessions within two weeks, addressed vali-dated pain assessment tools and the documentation of pain assessment. Descriptive frequency analysis and partial correlation with Pearson's r -value were used, with P < .05 indicating significance.Findings: Postintervention, pain assessments in general increased significantly from a mean of two times per patient to three times. Overall, the use of assessment tool Critical-Care Pain Observation Tool increased from 6.1% to 25.8%, opioid consumption increased in mean from 3.34 to 4.79 in milligram and the documentation at discharge increased from 81.4% to 91.4%. The documentation of nurses with more than 10 years' experi-ence in the unit especially improved from 17.5% to 31.7%.Conclusions: Educational intervention and reminders about basic systematic pain assessment and the evaluation of pain measures improved nurses' documentation of postoperative pain management and documentation at discharge. The findings underscore the importance of regularly ensuring the quality of patients' treatment by systematically documenting nurses' clinical tasks and the outcome of patients' care.(c) 2022 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.