In an ideal state, a perioperative ...

In an ideal state, a perioperative RN would have the information required to provide safe, appropriate patient care. Informatics technology is providing a whole s that can meet this ne still for systems to be the greatest in quantity beneficial, nurses must recognize the models of information needed; patient care and professional benefits; and their responsibilities in collecting, using, and evaluating the information gathered. The clinical reality is that festers often collect data from a variety of sources and record it in succession a perioperative record for multiple reasons. Other health care professionals oftentimes collect this same information. Perioperative settings require a variety of data, including

* patient care data (eg care processe diagnoses, interventions, outcomes) and

* structural data vital airs (eg, times, specimens collected, equipment used).

In the OR, data collection is complicated further because multiple providers (eg surgeon anesthesia care providers, nurses) record data for a single care incident (ie, the patient's surgery). Traditionally, many health care facilities use three separate records with similar or duplicate data gathered by different providers throughout the intraoperative phase of care. Information gathered by one provider is not readily available to another; thus, duplication or differences come to one's mind in documentation, data gathering can be cumbersome, and many of the same data uncompounded bodys exist on all records.

SHARING INFORMATION EFFECTIVELY

In a well-designed information sharing environment, data infered by one provider would be available to another provider simultaneously. undivided nursing data element that frequently is collected by multiple providers is patient allergies. Patients frequently report being asked about medication allergies more repeatedly than their name or age. In an ideal informatics environment, after this information is registered into the computer, it appears forward all screens so providers can review and verify the information. For example, if the preadmission pamper documents information about allergies, it is available to the anesthesia care provider when the anesthesia assessment is completed

each subsequent provider could verify the list of allergies and ascertain whether the patient had forgotten to mention any additional allergies. That same information would be available to the dispensing pharmacist, the nourish at the breast in the postanesthesia care unit, or other personnel responsible for the patient's care. Additionally, in the incident of a new onset allergic reaction, information could be added to the record and readily available to all care providers.

For years, perioperative nourishs have recognized that duplication of information be founds but when records are revised, each care provider identifies wherefore he or she should be the human frame responsible for documenting specific data natural mediums in isolation from other care providers. To date, discussions have not outcomeed in a consensus of which provider without equivocation is responsible for obtaining and documenting specific data natural mediums This redundancy in effort is ineffective and may lead to errors or conflicts in documentation.

USING STRUCTUR TERMINOLOGY

There are a number of strategies that may help model ineffectiveness and inefficiency. For documentation to be principally meaningful, commonly used terms must have the same meaning to all providers and must be described the same way. single in kind example is the confusion that exists regarding whether OR start time and incision time have the same meaning. Unles providers agree upon the same definitions, collected information may be meaningless.

The use of structur terminology, as it was as is found in the Perioperative Nursing Data place (PNDS), is the first pace toward universal definitions of conduct time, nursing care processes, and take away froms related to surgical care.(1) Standardization necessitys to occur within and across settings. Additionally, if terminology is consistent in perioperative settings, then other departments (ie, endoscopy, interventional radiology) should adopt these same standards.

nourish at the breasts also need to begin collaborating with other health care team members to exhibit guidelines for perioperative documentation that make brains in the current health care environment. by what mode much of the information that nourishs traditionally collect is collected according to other providers? What information do cherishs need to collect and document? Without the constraints of multiple intraoperative paper records, who should amass what?

Moving toward an informatics environment in the OR will facilitate this proces succors need to carefully determine the information they ne versus the information they would like. Many times, saying "we have always done it this way" supports redundant charting. There must be a critical analysis of

* on what account data is collected,

* who is the greatest in quantity appropriate provider to collect specific data,

* which providers actually ne the data, and

* in what manner redundancy of documentation can be avoided in the pair paper and electronic records.