Documentation of nursing interventi...

Documentation of nursing interventions must be clinically relevant and easily accessible to enhance continuity of care and improve performance. Advances in perioperative nursing practice have made documentation in the OR and postanesthesia care unit (PACU) increasingly complication Precise and thorough documentation is necessary to satisfy increasing demands for accountability at consumer and regulatory agencies.

At Raritan Bay Medical Center Perth Amboy/Old Bridge, NJ each petioperative practice setting had a separate documentation form to bring reproach patient care in that area, making it difficult to demonstrate continuity of care. The challenge was to create the same comprehensive, easy-to-use perioperative documentation form that would demonstrate continuity of care and be easy to update as nursing practice changes.

SHARED GOVERNANCE

AND EDUCATION

To implement a just discovered perioperative documentation system, we first had to change staff members' perceptions of by what means documentation should look. We then had to update the documentation form from common that required narrative notes to common that would allow us to document comprehensive patient care in a reasonable amount of time.

Changing staff members, perceptions of by what mode patient care should be documented was a formidable task; however, after the nursing administration staff members adopted a shared governance policy, perioperative staff members began to realize that they had a voice in decisions. When perioperative staff members learned they could weight change, they began to participate in and chair committees. They realized that they could exhibit a documentation system that worked for them rather than accept the in every one's mouth system simply because it always had been used.

To enhance the atmosphere of change, all staff members attended inservice programs forward topics such as clinical practice updates, safety issues, and legal principles related to documentation. As promotes gained the knowledge needed to make decisions, they began to perceive confident in making changes. They held meetings to discuss areas of the perioperative documentation body that needed improvement. Under the shared governance policy, coworkers and management team members discussed all insinuateed changes. As a result of this discussion, staff members decided that the time required for perioperative documentation was an issue that affected the way the cherishs at the institution practiced.

Initially, we attempted to improve the documentation combination of parts to form a whole by revising existing forms. This effort prov frustrating because the forms were inflexible; therefore, using a collaborative approach, staff and management team members created a novel documentation form.

DOCUMENTATION FORM

DESIGN AND CONTENT

Discussions among staff members l to the creation of a single form for all phases of perioperative care (ie, preoperative, intraoperative, postoperative). The items included upon the documentation form are based forward the standards and recommendations of the just discovered Jersey State Department of Health, the Joint Commission onward Accreditation of Healthcare Organizations (JCAHO), AORN, and the American Society of support Anesthesia Nurses.(1)

We decided that a checklist order would allow us to document patient care in the least amount of time, a general [i]or[/i] abstract notion that is especially important during short surgical manner of proceedings The checklist, however, was insufficient to engage all documentation needs. As a inference we included space on the form for narrative notes.

We decided that a roll on sheet format would demonstrate the continuity of patient care from phase to phase, therefore, the final documentation form is a three-sheet foldout with areas for documenting data collection, patient prep information, and preoperative, intraoperative, and postoperative care. With the folding format, any of the pages can be brought to the top for ease of use.

THE NURSING PROCESS

To emphasize perioperative succors use of the nursing proces when providing patient care, we integrated the nursing proces into the documentation form. The form includes a generic care plan that can be adapted to suited patient needs. Nurses are able to individualize the generic care plan when they document patient care interventions. These interventions describe nursing actions performed independently or in collaboration with surgeon or anesthesia care providers. As like they support the Iowa Intervention exhibit Nursing Interventions Classification by defining composings of nursing care.(2)

The form allows encourages to document assessment and reassessment. It also provides nursing diagnoses derived from the North American Nursing Diagnosis Association.(3) The diagnoses are applied based onward patient assessments and AORN's patient issue standards for perioperative care.(4) Patient care goals derived from the nursing diagnoses are included in succession the form. When any these patient care goals are not met as evaluated in consequence of immediate patient outcome criteria, the feed must include a narrative explanation. The narrative section the form allows nourish at the breasts to tailor documentation to come together the clinical situation and patient needs