Documentation of Pain Care Processes Does Not Accurately Reflect Pain Management Delivered in Primary Care

This article examines how well the documentation of pain care in a primary care setting reflects patient reports of pain care. Current quality initiatives strive to improve the quality of pain care in the medical system, but are hampered by a lack of information on how well pain and pain care is documented. The authors assessed how well physicians documented pain care and also examined the association of patient reports of pain care with pain outcomes.

Researchers collected information from 237 adult patients reporting pain in an internal medicine clinic affiliated with a university. The mean age of patients was 54 years, approximately two-thirds were female, and three-quarters reported chronic pain. Patients were asked to report pain severity and pain treatment at the time of visit and again one month later.

Key Findings:

  • Patients were more likely to report having received pain treatment (67%) than physicians were to document pain treatment (54%).
  • In multivariate models, physician documentation of new pain treatment was not associated with a change in the patient’s reported level of pain. However, when patients reported receiving new pain treatment, they were more likely to report pain improvement after one month.

This research documents the complexity of pain care management and documentation. It suggests that patient reports of pain management and treatment may be more accurate than physician documentation of pain treatment.