ABSTRACT A 14-member task force a...

ABSTRACT

A 14-member task force appointed by the agency of the AORN Board of Directors began the proces of identifying perioperative nursing data components in November 1993. During the ensuing couple years, the task force members identified perioperative nursing intervention data ultimate parts linked these data elements to specific patient results and asked 232 AORN members to validate the list of intervention data constituents This article explains to perioperative supply with nourishments describes the consensus process used by the agency of the task force, and not past nor futures the Perioperative Nursing Data Elements: Intervention, Version 10 AORN J 63 (May 1996) 926-931

An automated, standardized arrangement of naming what nurses do is wanted to clarify the value, issues quality, and cost-efficiency of professional perioperative nursing services.(1) Unfortunately, necessary data are not available to describe the patient moot points perioperative nurses manage, the actions they take to shelter patients from those problems or to melt those problems, the patient consequences they achieve, and the resources they use to accomplish patient issues The benefits of professional perioperative nursing services will continue to be invisible to administrators, financial officers, and health care policymakers until a uniform, systematic, computerized record of perioperative nurse/patient activities becomes a reality. What is requireed is a unified nursing language rule that links the information scrape togethered in individual hospitals and clinics to a often met with vocabulary used by perioperative supply with nourishments across the nation.(2) Data constituent principles are the information units that perioperative cherishs can use to build this usual vocabulary.

DATA ELEMENTS

The smallest unit of information (ie, data) that has meaning and that can be managed electronically is bourned a data element.(3) Any basic fact, material, or observation can be a data constituent principle Data elements are found in patients' records as well as in make acceptableed practices, critical pathways. standards of practice, agency policies, direction documents. and a variety of technical step manuals (Figure 1).

Data vital airs can be divided into three categories: global, focal, and numerical. (The conception of these three data constituent categories evolved from the author's application of mind and does not necessarily show the philosophy of the AORN Task Force forward Perioperative Data Elements.)

Global. A global data component part has a common definition across many clusters An example of a global data proper sphere is time. When the numerals 10:30 are written forward a document, readers recognize that the numerals indicate a time of day. Age and date are other examples of global data elements

Focal. When a data ingredient is defined clearly by single in kind group of individuals and can be articulated to other clusters of individuals, it is focal (ie, focused in succession one group). For example, a cluster of perioperative nurses would understand a discussion of damage classification criteria. It would not be necessary to define the terminus wound classification for this cluster of individuals. A member of this perioperative nursing collection could articulate the concept of this focal component (ie, wound classification) to other individuals, describing the difference between Class I pain s (ie, low risk for nosocomial infection) and Class IV injurys (ie, purulent infection).

Numerical. Many data constituent principles applicable to nursing are too mingled to summarize in a scarcely any words. They require statements with defined characteristics that can be given numerical digests (ie, numerical data elements) Examples of numerical data ingredients include the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and the Clinical course and Techniques (CPT) codes.(4) The ICD-9-CM is a listing of diseases with attached descriptions, which are assigned to patients at the time of discharge. In the United States, third-party payers use ICD-9-CM digests to determine payment to agencies. The CPT digests are a method health care professionals use to charge for individual services they return to patients. Each CPT digest has a list of criteria that describe the services provided. Nursing diagnoses and nursing interventions could be numerical collection of lawss For example, a code could be used to portray a nursing diagnosis made or a perioperative nursing intervention delivered.

Perioperative pampers analyze many facts (eg, laboratory trial values, patients' vital signs), observations, and narrative observations before making clinical judgments about the nursing care patients ne in the same state [i]or[/i] condition facts represent another source of perioperative nursing data uncompounded bodys The information recorded before, during, and after operative or invasive proceedings (eg, surgery start times, positioning devices used, hurry points padded, surgical skin preparation methods) are potential perioperative nursing data elements

When perioperative encourages across the nation begin to use the same data component nomenclature and the same definitions for each data vital air and begin to enter the same data components into computerized records, a perioperative nursing data station will be available for comparative analysis. If of that kind a data set existed generally perioperative nurses could use it to answer questions similar as "Do hospitals that implement major store reductions (eg, by downsizing professional nursing staff members) have different patient results than hospitals that implement minor collection reductions?"