From patient admission to discharge, pain is a critical symptom of concern to the nurse case manager. This descriptive study examined nurses' decision-making regarding pain management as documented in clinical records of patients after orthopedic surgery. Using a Nurses' Pain Management Audit Tool, data analysis revealed that during the first 24 hours after emergence from the Post-Anesthesia Care Unit, these patients received less than 50% of the narcotic doses available for their pain relief. Nurses documented less than 25% of the "ideal occurrences" possible for pain assessment, as described in the Agency for Health Care Policy and Research Guidelines. Incomplete databases for guiding patient outcomes of effective pain management were perpetuated by insufficient documentation. Nurse case managers could stimulate increased commitment and quality improvement in pain management as a crucial aspect of patient care.