The following commited practices we...

The following commited practices were developed by the AORN commended Practices Committee and have been approved from the AORN Board of Directors. They were existinged as proposed recommended practices for annotate by members and others. They are effective Jan 1 2000

These make acceptableed practices are intended as achievable recommendations representing what is believed to be an optimal plain of practice. Policies and operations will reflect variations in practice settings and/or clinical situations that determine the step to which the recommended practices can be implemented.

AORN recognizes the numerous impressed signs of settings in which perioperative cherishs practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and other invasive acts may be performed.

Purpose: These make acceptableed practices provide guidelines to assist perioperative nurtures in documenting nursing care in the preoperative practice setting. Documentation using the nursing proces should be complet for each surgical and other invasive management The nursing process is a formalized, systematic approach to providing and documenting patient care. Perioperative documentation is essential for the continuity of goal-directed care and for comparing achieved patient issues to expected patient outcomes.

make acceptableed PRACTICE I

The patient's record should think the perioperative patient's plan of care, including assessment, diagnosis, issue identification, planning, implementation, and evaluation.

Interpretive statement 1:

Documentation should include information about the status of the patient, nursing diagnoses and interventions, rely uponed patient outcomes, and evaluation of the patient's answer to perioperative nursing care.

Rationale:

The nursing proces provides the governing framework for documenting perioperative nursing care. When the nursing proces is used in perioperative practice settings, it demonstrates the critical-thinking skills practiced at the nurse in caring for the surgical patient.(1)

Interpretive statement 2:

The patient's record should cast reproach an assessment (ie, physical, psychosocial, cultural, spiritual) performed from the perioperative nurse before surgical or other invasive procedures

Rationale:

A documented assessment forms a baseline for developing nursing diagnoses and planning patient care. Continuing this assessment completely through each subsequent phase of the patient's care (ie, intraoperative, postoperative) contributes to continuity of care.(2)

Interpretive statement 3:

The patient's record should mirror the plan of care.

Rationale:

The planning proces begins when the perioperative feed identifies nursing interventions that will address the patient's actual or potential risk for health point in disputes (ie, nursing diagnoses). Documentation facilitates communication among health care team members, elevates continuity of care, and labor fors as a legal record of care provided.(3) Identifying desired patient issues that are individualized, prioritized, measurable, realistic, and obtainable aids in developing the plan of care.(4)

Interpretive statement 4:

The patient's record should specify what nursing interventions were performed and when, where, and by means of whom during each phase of perioperative care.(5)

Rationale:

The implementation proces is a come of assessment and planning using nursing understanding and critical thinking skills. The goals of nursing interventions are to obstruct potential patient injury or complications and to intervene/treat actual patient enigmas Documenting nursing interventions promotes continuity of patient care and improves communication between health care team members.(6)

Interpretive statement 5:

The patient's record should ponder a continuous evaluation of perioperative nursing care and the patient's reply to applied nursing interventions.

Rationale:

The nursing proces directs perioperative cherishs to evaluate the effectiveness of nursing interventions toward attaining desired patient issues The evaluation process provides information for continuity of care, performance improvement activities, perioperative nursing research, and risk management. Documentation provides a mechanism for comparing actual versus look forward toed patient outcomes.(7)

Interpretive statement 6:

Perioperative documentation should include, if it be not that is not limited to,

* identification of individuals providing perioperative patient care (ie, name, title, signature of [i]role[/i] responsible for the care);

* description of patient's overall skin condition upon arrival and discharge from the perioperative suite;

* perioperative patient care planning, including baseline physical, emotional, psychosocial, and cultural data;

* personality and/or disposition of sensory aids and prosthetic devices (eg eyewear, hearing aids, denture artificial limbs);