The following attract favor toed p...

The following attract favor toed practices were developed by the AORN commited Practices Committee (RPC) and have been approved by the agency of the AORN Board of Directors. They were published as propos approveed practices in the August 1995 AORN Journal for annotate by members and others.

These praiseed practices are intended as achievable recommendations representing what is believed to be an optimal of the same height of practice. Policies and conducts will reflect variations in practice settings and/or clinical situations that determine the grade to which the recommended practices can be implemented.

AORN recognizes the numerous emblems of settings in which perioperative fosters 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 laboratories, endoscopy suites, radiology departments, and all other areas where surgery may be performed.

intent These recommended practices provide guidelines to assist perioperative nourishs in the documentation of nursing care in the perioperative practice setting. Documentation, using the nursing proces should be complet for each surgical and other invasive proceeding 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 the comparison of achieved patient consequences to expected patient outcomes.

RECOMMEMD 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:

The patient's record should throw back an assessment (ie, physical, psychosocial, cultural, spiritual) performed by the agency of the perioperative nurse prior to surgery or other invasive procedures

Rationaie:

A documented assessment forms a baseline for the exhibition of nursing diagnoses and planning patient care. This assessment continues between the sides of each subsequent phase (ie, intraoperative, postoperative) and provides for continuity of care.

Discussion:

During the assessment proces the perioperative cherish collects data about the patient's status. The ongoing proces of assessment should be performed in accordance with the AORN "Standards of perioperative clinical practice."

Interpretive statement 2:

The patient's record should mirror the care planned by perioperative nurses

Rationale:

Documentation of the perioperative plan of care should include nursing diagnoses, prescribed nursing interventions, anticipateed patient outcomes, and an appraisal of the quality of care delivered.(2)

Discussion:

The planning proces begins when the perioperative encourage identifies nursing interventions that will address the patient's actual or potential risk for health question s (ie, nursing diagnoses). The goals of nursing interventions are to hinder potential patient problems or to intervene in actual patient question s Patient outcomes should be individualized, prioritized, measurable, realistic, and obtainable.(3)

Interpretive statement 3:

The patient's record should specify what nursing interventions were performed and when, where, and at whom during each phase of perioperative care.(4)

Rationale:

Documentation of nursing interventions prefers continuity of patient care and improves communication among health care team members.(5)

Discussion:

The implementation proces is a originate of assessment and planning, utilizing nursing discrimination and critical thinking skills. Nursing interventions are implemented to treat patient point to be solved [i]or[/i] settleds and to prevent potential patient injury or complications. Documentation of all nursing activities performed is legally and professionally important for clear communication and collaboration among health care team members and continuity of patient care.

Interpretive statement 4:

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

Rationale:

Documentation provides a mechanism for comparing actual versus count uponed patient outcomes.(6)

Discussion:

The nursing proces requires that perioperative promotes evaluate the effectiveness of nursing interventions toward the attainment of patient results The evaluation process provides information for continuity of care, quality improvement activities, perioperative research, and risk management.

make acceptableed PRACTICE 11

Policies and processs regarding documentation of perioperative nursing care should be written, reviewed annually, revised as necessary, and readily available within the practice setting.

Discussion:

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 considerations and actions taken by the nourish in the care of the surgical patient.(7)